Wiki Handedness

[Inquisitor]

Any input on how you would count "patient is right handed" in the history? I believe it would count as constitutional ROS since it establishes baseline data pertaining to the methods the body uses to function. Especially important if the patient has a "right hand" injury.

Appreciate your thoughts...

 

[LLovett]

I would say it is a muscle skeletal element in ROS.

Just my take,

Laura, CPC

 

[Inquisitor]

Thanks. Boss isn't going for that one. Says it counts as nothing. Anybody else want to pipe in? I think it should count for something since it is significant.... Help!

 

[ARCPC9491]

This might be REALLY stretching it... but what about modifying factor? being right handed with a right hand injury certainly modifies your day to day activities. The only thing though is that it doesn't modify the injury, but rather the person. I don't know, this is a good question.

 

[FTessaBartels]

Can you post the entire history?

We're operating in the dark ... or at least dusk ... here. Can you post the entire history section?

F Tessa Bartels, CPC, CEMC

 

[Inquisitor]

"CHIEF COMPLAINT:
Patient is a 38 year old male employee of Conagra Foods who complains about his arm which was injured on 01/26/2009 9:30:00 AM.

PATIENT STATEMENT:
Patient states :""Cut with razor knife.""
Statements above auto populate from electronic data entry by ancillary staff.

Allergies: No known allergies.. Current Medications:
Norvasc by: L A D.

HISTORY OF PRESENT ILLNESS:
Patient seen immediately due to the emergent nature of the injury. Patient cut his right thumb at work today on a clean, new razor blade knife. The patient is left handed.

PAST MEDICAL, SOCIAL, FAMILY HISTORY: Noncontributory based upon review of comprehensive questionnaire.

Current Medications: The medication list was reviewed.
Allergies: Denies known allergies.
Immunizations: Not up to date.

ROS:
GENERAL: Denies fever, chills and recent weight loss/gain
CHEST: Denies DOE, cyanosis, wheezing, cough and sputum production.
CARDIOVASCULAR: Denies chest pain, PND, orthopnea or reduced exercise tolerance.

Also curious if you would count Chief Complaint/Patient Statement as Chief Complaint since entered by ancillary staff.

 

[FTessaBartels]

Left Handed

For HPI:
QUALITY - Emergent injury
Location - right thumb
Context - at work on clean new razor blade
Modifying factor - patient left handed

For ROS and PFMSH
physician states that questionaire is reviewed ... if that section has been completed you have your ROS and PFMSH

Chief Complaint:
YES, I'd count it ... you even have a section "PATIENT STATES" - in purest terms the chief complaint is what the patient says is wrong.

F Tessa Bartels, CPC, CEMC

 

[Inquisitor]

"Patient states:" is autopopulated from ancillary staff, not performed by the provider. Does that make a difference?

 

[Lisa Bledsoe]

"Patient states:" is autopopulated from ancillary staff, not performed by the provider. Does that make a difference?

As long as the HPI is documented by the provider it is ok. You have the "auto-populated" statement and then what appears to be the HPI from the provider.