Wiki "duration" in HPI

[jek521]

Our hospitalists often admit patients from the ER & I would appreciate any thoughts on this component for the initial hospital visit.

I've always seen "duration" explained in terms of a specific amount of time (e.g. 3 days, since last Tuesday, pt's whole life, etc.).

I am wondering if it could also be credited for a specific series of events, such as "pt fell, came to the ER, found to have hip fracture, admitted for surgical intervention." Does it need to be stated that the patient fell "today" or "2 hours ago"?


Thanks!!
Jen

 

[FTessaBartels]

Time frame has to be included

In order to count duration the time frame has to be specified. Somehow they have to be explicit as to when the problem first appeared ... "noticed on X-ray mm/dd/yy" or " yesterday" or "since birth."

Hope that helps.

F Tessa Bartels, CPC, CEMC