How many HPI elements?

shellabell32

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Happy Friday!

I am trying to audit my Doctors for their hospital consults/admissions/visits. I have trouble sometimes identifying HPI elements and I am afraid I am leaving some on the table. For the following HPI I only see three elements. Wondering if there are any I am missing.

This is a 73 year old woman who presented with 3 days of abdominal pain and distention. She was having complaints of nausea and vomiting for a few days prior to admission. CT scan on admission shows demonstrated wall thickening and luminal narrowing of the sigmoid colon with proximal dilatation of the large bowel. The patient last had a colonoscopy in 2012 and seen to have diverticulosis although the scope could only be advanced to the sigmoid colon secondary to severe tortuosity and was thickening. The colon was biopsied at that point in time and seen to have only benign disease. The 3D colonoscopy in 2013 demonstrated thickening of the sigmoid colon with luminal narrowing as well.


This is all listed under the HPI though it seems a good part of it is history. They had the reason for consultation/CC listed separately as Large Bowel Obstruction

I appreciate any help, as I watch and read how to properly code E/M it makes perfect sense until I actually try to do it :p
 
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I get four:
Location - Abdomen
Quality - Distention <--- this is where I think a question mark comes in
Duration - 3 days
Associated Signs and Symptoms - nausea and vomiting

Typically Quality is described as "description of type of pain", but in every training course I've had, Quality has been defined differently. For example, several courses from AAPC define it as "A problem’s characteristics, such as how it looks or feels (eg, yellow discharge, radiating pain, burning urination, etc.)".

"Distention" needs to be included somewhere, and that's where I put it based off what I've learned. Ultimately it's your call.
 

shellabell32

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Thanks for the reply! I was counting under associated signs and symptoms, but your take also makes sense. I like things to be black and white and E/M's gray areas/subjectivity throw me off sometimes.
 

tjbd57

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I get three. Location: Abdomen - Associated: Pain - Duration: - 3 days I personally feel that distention falls under the associated signs and symptoms category and in this case can be used as a Review of System if needed. The rest seems to be history related as you stated
 
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I found a textbook covering auditing that I got at the beginning of the year and I went through the narrative again, but from an auditing perspective. I sort of shifted my thoughts around, but ultimately ended up with

"The Chief Complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter." Considering that, I put "Large Bowel Obstruction" as the CC, as that was the reason for the consultation, for the encounter.

"Location: Most complaints refer to a specific area of the body for example: abdominal pain, sore throat, knee swelling, etc." I put Abdominal (pain) here.

"Quality: Describe the pain as dull, stabbing, sharp, radiating, throbbing. Describe a laceration as jagged or straight, or describe a sore throat as scratchy. Describe how a problem looks, feels, or behaves. Describe acute versus chronic or stable versus worsening versus improving." I put Distention (swollen/enlarged) here.

"Duration: Typically, statements are made such as “Onset three days ago”, “Since last Monday,” since (date), “for about two months”, “yesterday”, “in the last two weeks”, “ approximately one year ago." Obviously the 3 days applies here.

These last two are what caught my eye -

"Context: It’s the one descriptor that has given auditors the most trouble. Look for statements that describe how a complaint occurred such as: “Injuries incurred in a motor vehicle accident”, “running down the steps”, sitting in a chair”, “playing sports”, etc. Includes: “found on chest x-ray”; “running down steps”; “fell off ladder”; “injuries incurred in a motor vehicle accident”; “sitting in a chair”; “playing sports”; “dairy products”; “big meals.” Following this definition/explanation, I put the CT scan here because that's how the CC was discovered. I'm not 100% sure how I feel about this, but I filled out the audit form counting the CT anyway.

"Associated Signs and Symptoms: Describe any additional sensations or feelings or other factors that may be related to the complaint. Patients who describe the scratchy throat with nasal congestion and low grade fevers, are describing not only the chief complaint, but also the associated signs and symptoms. Usually these signs and symptoms are volunteered by the patient. Some of the examples could be counted in more than one area. Keep in mind, however, that you should only count a statement once, regardless upon which descriptor you decide it relates to. Consider “patient with (scratchy sore throat) has nasal congestion and low grade fever”. Hint: Look for other things that happen when the symptom/pain occurs." I put nausea and vomiting here.

In total, I get 5 using the book's audit form and directions.

That being said, I feel 100% about putting the distension into the Quality category because that's something visual and/or able to feel on touch - it describes how the abdomen looks/feels. But I hesitate on the CT scan because I've never used it before in this way. Even if I exclude that, I still get 4. Either way, I end up with, and totally agree with, an Extended HPI.
 
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