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Wiki Help with HPI and ROS

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ckelder

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I am having trouble deciding what should be counted as HPI and ROS in the following note. Any help would be greatly appreciated.

HPI
Here to f/u numerous abnormal labs from last week. Not seen by MD in over 15 yrs. Has been feeling fatigued. Has had 10 lb weight loss over past two months. She continues to feel nauseated and lightheaded, particulary in the morning. Feels weak and shaky. Feels better later in the day.

No change in bowel habits. She hsa noticed some blood when wiping once in awhile, which she attributes to hemorrhoids. No black, tarry stools, no pencil thin stools. Has occassional loose stool. No fevers or night sweats.

She has varied diet , eats meat. Has been diagnosed with malabsorption and pernicious anemia in her 30s. States she has not had it tested again. Was getting B12 inj in her 50's but stopped.

ROS- See HPI

Ideas???
 
I found this to have a Comprehensive HPI, and Det ROS. Hope this helps give you an idea :)

Kelsey, CPC, CEMC


HPI
Here to (Chief complaint)-f/u numerous abnormal labs from last week. Not seen by MD in over 15 yrs. Has been feeling fatigued(associated signs/symptoms). Has had 10 lb weight loss over past two months(duration). She continues to feel nauseated and lightheaded(ROS-GI, neuro), particulary in the morning(timing). Feels weak and shaky(constitutional). Feels better later in the day.

No change in bowel habits(GI again). She hsa noticed some blood when wiping once in awhile(possibly context, depending on your employers rules-we would count this under my hospitals guidelines), which she attributes to hemorrhoids. No black, tarry stools, no pencil thin stools. Has occassional loose stool(gastro). No fevers or night sweats(constitutional).

She has varied diet , eats meat. Has been diagnosed with malabsorption and pernicious anemia in her 30s(past history). States she has not had it tested again. Was getting B12 inj in her 50's but stopped.

ROS- See HPI
 
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