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Pilar10

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Can you “extrapolate” the HPI from the assessment and plan if the current problems are described as stable or worsening, etc? Or do I have to document the information in the actual HPI?. Thank you so much for all your responses.
 
Assesment not History

Interesting question. As we know HPI elements don't necessarily have to be in an area in the chart labeled HPI. And we often find HPI's elsewhere on the chart. My concern is that if it is specifically in assessment and plan, wouldn't "worsening" represent more of a post exam finding than a History that patient presented with. I'd lean against it, but open to other interpretations. Jim
 
I often find that my doctors document better the HPI in the assessment than in the actual hpi. For example, patient woke up at 11 o'clock last night with chest tightness that has been going on and off since then. There are four hpi elements that I would be able to use I just was not sure if it needed to be stated in the actual HPI. Thanks.
 
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