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HPI Documentation Help


Yakima, Washington
Best answers

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!!!



Best answers
Hopefully your physician did not get his patients confused or mixed up, took and documented a Chief Complaint and HPI and the performed and documented an examination of the patient's shoulder for a complete note for the visit. Often patients will say "While I am here, will you look at my foot? It has been bothering me too." In order to "charge" for the foot problem, he would need to add an additional Chief Complaint, pertinent HPI, and a Diagnosis for the foot problem as well. In essence, the patient was seen for 2 problems, both of which warrant complete documentation, particularly if the E&M Charge is going to include 2 problems.

Respectfully submitted, Alan Pechacek, M.D.