Wiki E&M

[ktden]

I have just started coding E&M services and need help with some definitions.
Within the HPI, could someone give me a description of the terms:

1) location
2) quality
3) severity
4) duration
5) timing
6) context
7) modifying factors
8) associated signs and symptoms

 

[RebeccaWoodward*]

B. History of Present Illness
HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are:

Location. For example, pain in left leg;■■
Quality. For example, aching, burning, radiating;■■
Severity. For example, 10 on a scale of 1 to 10;■■
Duration. For example, it started three days ago;■■
Timing. For example, it is constant or it comes and goes;■■
Context. For example, lifted large object at work;■■
Modifying factors. For example, it is better when heat is applied; and■■
Associated signs and symptoms. For example, numbness.


http://www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp

 

[mitchellde]

Good job Rebecca! I like it.

 

[ktden]

Great,
Thank you so much!!!!

 

[FTessaBartels]

Each element defined with a question

Location - Where - the site, is it diffuse, localized?

Quality - What kind - sharp, dull, constant, intermittent

Severity - How bad is it - pain scale 1-10, mild, severe

Duration - How long has it been present - since yesterday, for 2 weeks, fell on Tuesday

Timing - Is there a pattern - every morning, continuous, repetitive

Context - What Brings it on - with exercise, when standing, noted on X-ray

Modifying factors - What makes it better or worse - better with Tylenol, Rx had no effect

Associated Signs - What comes with it - other symptoms that accompany the chief complaint.

Hope that helps
F Tessa Bartels, CPC, CEMC