Wiki Grading case history for a single organ system

[AWenger]

my question is:

How do you get a problem focused history in a single organ system? Even if you get a brief HPI and no PFSH you still will always have a problem pertinent ROS because you will ALWAYS be dealing with one system. Therefor the minimum case history will always be expanded problem focused. Is that correct? I work in optometry and so i will always have the "eye" So even if the doc had a brief HPI and NO PFSH the ROS will always be problem pertinent. I am having a hard time accepting that and really would like to know how would you get a "problem focused Case History" in a single organ system?

Any help with this would be great! Thanks!

 

[LindaEV]

A "problem focused" history can be acquired with ONLY a brief HPI, and no ROS/PFSH.

an "expanded problem focused" history requires a brief HPI and ONE ros. If the Eye is documented in the HPI and the ROS, then you have the EPF Hx.

So to answer your question, I'm thinking it would be HARD to get only a problem focused Hx in your case unless the ROS is just not documented. Just make sure you are not double dipping since you are dealing with the same system!

In this case it would actually be pretty easy to document the HPI and ROS in one lump statement.

"Pt c/o of redness and watering in rt eye for three days. No colored drainage, no pain, no blurred vision. No complaints in lt eye." (first sentence HPI, second is ROS)

 

[AWenger]

Thank you- that is what i was thinking. I thought it would be pretty hard but i thought i would double check. Sometimes i know something so well that i begin to question myself so i really appreciate it.

Thank you!!!

 

[AWenger]

double dipping

Hi Linda- after i re read what you wrote i saw the term "double dipping" i wasn't very familiar with that so i looked at some forums and found out. I would like some clarity on it. You said be careful of double dipping so my question is if the patient comes in and the HPI states: OS red for 2 days.

I then counted location: OS
quality: red
duration: 2 days
So HPI brief

Then for ROS i would count eye

Is that incorrect? Should i not be counting the eye for ROS?

However, i am confused because it always states which eye is the problem in the HPI generally and if i can not count the eye for ROS then that would not work either. working in a specialty i get confused. Can you write me back and explain what "double dipping" would mean for someone who works in a single organ sytem?

Thanks!

 

[FTessaBartels]

Double Dipping

You cannot count the same verbiage for two different things - that is double dipping.

In your example:
HPI states: OS red for 2 days.

I then counted location: OS
quality: red
duration: 2 days
So HPI brief

Then for ROS i would count eye

You cannot count anything you counted for HPI as ROS. So if you are counting location, quality and duration as HPI you have NO ROS.

Better to have your physician document some negatives - for example: no itching or weeping. Those negatives would easily be ROS eye.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[AWenger]

Confused

Thank you for replying and it does help but i am still confused. So if i counted all of that for HPI then i WOULDN'T"T have an ROS? I thought that i would always have 1 ROS for eye because we are single organ. So we wouldn't have ROS if the term"eye" was already stated in HPI? Needing some more help-anything would be great!

 

[FTessaBartels]

You cannot double dip

Thank you for replying and it does help but i am still confused. So if i counted all of that for HPI then i WOULDN'T"T have an ROS? I thought that i would always have 1 ROS for eye because we are single organ. So we wouldn't have ROS if the term"eye" was already stated in HPI? Needing some more help-anything would be great!

Ali,
You cannot double dip. I do not know how to explain it more clearly. If you counted all the statements as part of HPI you have no statements left to count for ROS. Just the word "eye" is not enough to give you an ROS for that system.

F Tessa Bartels, CPC, CEMC