determine level of HPI--need help

jvalntine

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If a physician is asked by a surgeon to consult the patient --who is inpatient-- for medical management-- how do you determine level of HPI when there is no location, duration, quality etc to help make the determination. The physician only notes in the HPI section the procedure being done, and if the patient's systems are ok to have the anesthesia for the surgery, etc.
jv
 
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Can you post the scrubbed note?

Can you post the scrubbed note ... Was the physician looking at 3 or more chronic conditions?

F Tessa Bartels, CPC, CEMC
 
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