HPI “radiates” location or quality

cmsande

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If patient states “chest pain that radiates to left arm”
Would this be 2 elements
Radiates= quality
Left arm= location

Or

Radiates to left arm= location
 

Pathos

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CMS '95-'97 guidelines explain the following:

"History of Present Illness (HPI)
HPI is a chronological description of the development of the patient’s present illness
from the first sign and/or symptom or from the previous encounter to the present. HPI
elements are:
™ Location (example: left leg)
™ Quality (example: aching, burning, radiating pain)"


Based on the guidelines from CMS, I would suggest that you could count two elements from the statement provided.

Hope that is helpful!
 

cmsande

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Very helpful, thank you!
I always use as quality but while reading another article found that some coders use it as location, I started second guessing myself.
 
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