valwy
New
Can someone look at the documentation below and assist with scoring of HPI elements using MCR 1995 Documentation Guidelines. I see a definite 3 elements with a possibility of 5 elements with adding context and duration. Would appreciate opinions on the scoring.
Physician documents:
"The patient was seen in the office today. She is a lady with atrial fibrillation and a loop recorder. She is an extremely poor historian. She says that she had an episode of syncope. She does not remember the details. She did not activate the device. She also says that she gets light-headed on and off."
An episode of Syncope – associated signs & symptoms, (can duration be applied to episode?)
Light-headed on and off - associated signs & symptoms and timing
Does not remember the details – can context be used here (negative application)
Thanks.
Physician documents:
"The patient was seen in the office today. She is a lady with atrial fibrillation and a loop recorder. She is an extremely poor historian. She says that she had an episode of syncope. She does not remember the details. She did not activate the device. She also says that she gets light-headed on and off."
An episode of Syncope – associated signs & symptoms, (can duration be applied to episode?)
Light-headed on and off - associated signs & symptoms and timing
Does not remember the details – can context be used here (negative application)
Thanks.