How would you "score" this HPI?

tristate

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HISTORY: I saw Mrs. _______ for cardiological evaluation today. She is scheduled for right mastoid surgery on 04/23/09 at XXXXXX. During her evaluation at XXXXXXX, she was detected to have a cardiac murmur. She denies any exertional chest pain or undo shortness of breath. However, on account of unsteady gait, her activity is limited to household chores. She does manage to walk around the local mall at least twice a week. She admits to tinnitus in both ears. She also has a tendency to fall due to disequilibrium. She had a bad fall in September 2008 and sustained a fracture of her right wrist. She does not complain of headache, nausea, vomiting, or diplopia.

I get - Location, AS & S, Modifying Factors (Activity limited to household chores)

Anything else? Thanks!!! TGIF!!!!

Debby
 

deeva456

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I agree with location, AS&S and modifying factors. What about quality? would "unsteady gait" count as quality?
 

ollielooya

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how about "context?" During her evaluation at XXXXXXX, she was detected to have a cardiac murmur. Just my thoughts...not sure about the unsteady gait...Hope more will answer!
Suzanne-CPC-A
 

ARCPC9491

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Location - Ears, cardiac (possibly), right wrist
Quality - unsteady (gait), fracture
Severity - "bad" fall
Duration - MAYBE Sept 08...but I don't know if that's when probs w/ disequilibrium started..
Timing - once a week
Context - walks @ local mall
Mod Factors - household chores
Assoc Signs/Sx - as above
 

dmaec

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debsimnz - I get what you got... Location, AS & S, Modifying Factors .

I don't get Quality, Severity, Duration, Timing, or Context. I'm sorry, but I'd have to disagree. I believe those things pointed out fall under different area's; such as past medical history and AS&S. (and as such, can not be counted twice - or under both area's)

just my opinion.. :)
 
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Scoring the HPI

One reason I nag my doctors to separately state the chief complaint is so that I know what I'm looking at for the HPI - i.e. what is the present illness?

From your note I get:
Chief Complaint: cardiologic eval (I'm beginning to think this is a consult)

HPI: Cardiac = location
Murmur = quality
exertional = context (even tho this is negative, I give credit for his asking)
chest pain, SOB = assoc signs/symptoms

I've stopped counting because all I need are 4 to get to the comprehensive HPI.

I'd count everything else as either past medical history or ROS, depending on where I needed it.

Hope that makes sense.

F Tessa Bartels, CPC, CEMC
 
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