Wiki How would you code this interval history?

[jenpudua32]

Question regarding interval history.
What level of interval history is this:

Patient feels well. No abdominal pain.

Could I count 1 negative point towards GI for 'no abdominal pain and 1 point for 'well' for HPI? I was thinking this could qualify as quality... interval history confuse please let me know your opinion, thanks!

 

[natashalage]

hi. I am a new coder. it’s a tricky situation. I know that “feeling well” you can use for constitutional ROS and “no abdominal pain“ for GI ROS. Positive or negative count for ROS. But you are asking for HPI… I would use them for signs and symptoms only and not for Quality because it does not describe the condition for which the patient came for.

 

[ErikaLessard]

Question regarding interval history.
What level of interval history is this:

Patient feels well. No abdominal pain.

Could I count 1 negative point towards GI for 'no abdominal pain and 1 point for 'well' for HPI? I was thinking this could qualify as quality... interval history confuse please let me know your opinion, thanks!

hi. I am a new coder. it’s a tricky situation. I know that “feeling well” you can use for constitutional ROS and “no abdominal pain“ for GI ROS. Positive or negative count for ROS. But you are asking for HPI… I would use them for signs and symptoms only and not for Quality because it does not describe the condition for which the patient came for.

The first issue with this documentation is that you do not have a chief complaint. Without a chief complaint you can not assign associated sign/symptom because you don't know if no abdominal pain is related to the CC or not. Additionally, even if you had a CC, you really have no HPI and only ROS.