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todd5400

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I would like opinions regarding History bullets you count

78 yr old who fell at home. She was getting out of bed to go to bathroom with a syndopal episode. She fell hitting the face. She complains of pain between the shoulders and face. She sustained a rib laceration and nasal abrasion. She is amnestic to the fall.

Thanks in advance
Mary
 
I see context (for the fall)..

Location (shoulders)

Quality (pain, could you severity if it showed severity of the pain)

Associated Signs and Symptoms (laceration)

Any other opinions?

dscoder74 :)
 
I see...
context (feel getting out bed)

Location (shoulder)

Associated Signs and Symptoms (laceration)

I would not use pain as quality usually to use quality it would be (sharp/dull/throbbing ect)

So I believe there are 3 elements in this HPI
Robin Ingalls-Fitzgerald cpc,cemc,ccs,fcs
 
Hpi

I'm assuming that you have a separate chief complaint ... and that this is just HPI.

I see:
Context - getting out of bed w/ syncopal episode
Assoc signs - pain, amnesiac to fall
Quality - laceration & abrasion
Location - shoulder, face, rib, nose

Too bad the doctor didn't tell us WHEN she fell ... you'd have duration.

F Tessa Bartels, CPC, CEMC
 
What if there is no separate CC? Would you infer from the HPI that the CC was a head, shoulder, face problem and then count all the HPI elements within the statement?

Just wondering...
 
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