Wiki HPI and Physical Exam

[Clara1203]

I am in need of some clarification. I am new to the auditing world and would like to know if the location for the HPI can be pulled from the physical exam or if "Skin Infection" can be used as the location? I am doubting this due to "Skin Infection" can be ANY part of the body. I am asking due to a contracted auditor is saying that the medical report has 4 listed for the HPI (Location, Duration, Quality and Associated Signs and Symptoms).


Here is what is listed for the HPI:

Chief Complaint:



Pamela More is a 67 year old female complaining of Skin Infection.
The quality is best described as: erythematous; warmth; they deny: edema, tenderness.
The patient reports the durationof their symptoms as: more than 1 week.

The patient also complains of intermitant skin flusing.
The patient reports the durationof their symptoms as: since last december

The patient also complains of Fatigue.
The quality is best described as: lack of energy.
The patient reports the durationof their symptoms as: 4-6 months.
The timingof their symptoms is reported to be: occurring 74-50% of the time.

The patient also complains of Hypothyroidism Follow Up.
The timing of their symptoms is reported to be: medication taken before breakfast.
The following findings or symptoms are associated with patient's chief complaint: xerosis.

The patient also complains of Swelling.
The patient reports the duration of their symptoms as: 2-6 months.


Here is the "location" in the Physical Exam:

Dermatologic

Head

The skin is normal in color, texture, moisture, temperature, mobility and turgor. There are no abnormal lesions. The hair is in a normal distribution with a normal texture.
Bacterial Infection
This patient's wound is erythematous ear

 

[thomas7331]

HPI is the history taken from the patient's account of the illness; exam findings are based on the observations made by the provider. These are two separate things and not interchangeable, so you can't take HPI from the exam.

However, the exam you have included in your example above already has four elements - as you've highlighted, the timing is documented, so you don't need location. But even without that, it could be argued that 'skin' is in fact a location, it's just not very specific.

 

[Clara1203]

Thank you for you quick response. I wanted to make sure that this is in fact an acceptable location.

 

[lizcon98]

Hello, I have a question regarding auditing. I am new as well to the auditing world and have trouble as well with the HPI and getting all the elements needed. I work for Pediatric Cardiology and I recently started noticing one of the providers does not do a cardio under the ROS, she has 10 but cardio is not one. I’m thinking she needs to have cardio since that’s our specialty or am I wrong?