Wiki Double Dipping? HPI and Exam

[AprilSueMadison]

I have a doctor who is writing "See HPI" in the exam portion of his notes.

So if the HPI states "Rash is red, scaly and on the patient's back and arms - as described" and then in the Exam portion of the notes under Integumentary states "See HPI"....I can't possibly count that towards his exam can I? First, the History isn't the exam...at this point the doctor should be documenting what the patient is stating, and second based on the comment "as described" it looks like the doctor IS writing what the patient is telling him.

 

[thomas7331]

You are correct, there is no overlap between HPI and exam. The HPI is the history of the problem prior to the patient's arrival at the encounter. The exam is the physician's observations. It's fine for the physician to refer to another part of the note for information, but for coding purposes, each piece of information only fits into one or the other.