Wiki HPI Documentation Help

[ajballard]

Hello,

I would like some clarification on the HPI documentation and your help is greatly appreciated. One of my providers in our Orthopedic office will see a patient for shoulder pain (documented in the HPI) but then will do a physical exam on the foot. Is this something they can include during the office visit?

Our thoughts are that they shouldn't be examining the foot when they are in for shoulder pain. Please guide me to the documentation that I can present to the provider to let him know if it is being done correctly or incorrectly.

Thank you so much!!!

-Amanda
asainsbury@ortho-nw.com

 

[clsteph1]

HPI Documentation Help - Does there appear to be a reason

Hi Amanda,

Does there appear to be a reason why he is examining the patient's foot? Does he also examine the shoulder? Is there a link between the two (i.e. does the patient have generalized osteoarthritis or some other related condition)? I would ask the physician if there is a link between the two. Is the HPI the only area where the shoulder pain is mentioned?

If he there is a reason (hopefully documented or inferable) both were performed, then I would not see a reason it could not be counted. However, it really would depend on the answers to the questions above.

Sorry - I'm not much help without a little more information.
Chandra