Wiki HPI Descriptors-definitions

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codingwithkelly

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I'd like to know if there's any documentation as to what each discriptor means and examples. Obvious is location, duration, severity, mod fact and as&s. We are disagreeing on the quality, timing and context. I have a "cheat sheet" I've been using for years but cant remember where I got it. Since it's a provider who is disagreeing with me I need the hard proof! Any ideas or web links you can offer would be great! Thanks. :cool:
 
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:
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Location. For example, pain in left leg;
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Quality. For example, aching, burning, radiating;
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Severity. For example, 10 on a scale of 1 to 10;
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Duration. For example, it started three days ago;
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Timing. For example, it is constant or it comes and goes;
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Context. For example, lifted large object at work;
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Modifying factors. For example, it is better when heat is applied; and
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Associated signs and symptoms. For example, numbness.

This is from cms, here is the link

http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


Laura, CPC
 
Hpi

Here's what I picked up from a recent seminar:
The 8 elements in the HPI are as follows:
LOCATION - where - the site, diffuse or localized
QUALITY - what kind - sharp, dull, constant, intermittent, improved/worsening
SEVERITY - how bad is it - pain scale 1-10, mild or severe
DURATION - how long - length of time it has been present
TIMING - is there a pattern - continuous or repetitive
CONTEXT - what brings it on - does it occur with a specific activity
MODIFYING FACTORS - what makes it better or worse - prior treatment or medication tried
ASSOC SIGNS & SYMPTOMS - what comes with it - symptoms that accompany the main complaint - could be negative (no pain, or no fever)

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Tessa ~

Thank you. That was what I was looking for. What seminar was it?

I'm also still wanting to know if there is a web site (besides CMS) that expands on the descriptors. Kelly Sanders, CPC
 
Medical Society of Wisconsin, Sept 2008

The Medical Society of Wisconsin holds a Coding Symposium each fall. The info on the HPI was on a handout from one of the sessions (about how to educate your physicians on proper documentation).

Glad I could help.

F Tessa Bartels, CPC, CEMC
 
FTessaBartels said:
The Medical Society of Wisconsin holds a Coding Symposium each fall. The info on the HPI was on a handout from one of the sessions (about how to educate your physicians on proper documentation).

Glad I could help.

F Tessa Bartels, CPC, CEMC
Click to expand...

Thanks for that info Tessa... I had a huge notebook full of notes for HPI and ROS and I just recently lost it...

I'm starting a new one with the wonderful info you just gave.

Thanks much!
 
A seminar that I attended had these examples

Quality:Any charateristic about the problem or how it feels or looks- "green" phlegm, "popping" elbow, "dull" ache, "sharp" pain, "metallic" taste

Timing:"intermittent", "constant", lasted "10 minutes", "occasional", "off and on"

Context:What the pt was doing/enviromental factors, etc.-"while sleeping", "slipped and fell", "when arguing with husband"

http://www.physiciansnews.com/business/708andress.html

Maybe this link will be helpful~
 
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