HPI and location

mteaford

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I have a question about the HPI elements. Can you use s/s when counting for location. Like SOB for lungs/resp or AMS for psych, etc?

Thanx!

Mary
 

Suresh46

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We can not consider SOB as location because it is sign and symptom and reflecting some disturbance in respiratory system. respiratory system contains a lot of body areas.
 

Pathos

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From the CMS E/M guidlines:

"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)
  • Severity (example: 10 on a scale of 1 to 10)
  • Duration (example: started 3 days ago)
  • Timing (example: constant or comes and goes)
  • Context (example: lifted large object at work)
  • Modifying factors (example: better when heat is applied)
  • Associated signs and symptoms (example: numbness in toes) "
I would be cautious to use a general rule on any of the above HPI elements, as one word can change the whole context of any chart paragraph. I could see cases where Location could be used towards a Sign and Symptom, and cases where it would be inappropriate to use Location towards a Sign and Symptom.
 
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