Wiki HPI Element Help

KaylaRieken

True Blue
Messages
506
Location
Waukee, IA
Best answers
0
The patient is a 25 year old male with intetllectual disability who was referred to us for evaluation for possible horomonal deprivation therapy due to his abnormal aggressive sexual behaviors at his care center. Patient presents here today with a staff member who states that the patient himself does growp female staff memebrs on a frequent basis and that is become more concerning and upsetting to the entire staff. The patient denies any voiding difficulties, history of stones, history of UTIs, hematuria. This staff member is unaware of any prior urologic history for this patient.

How many can I get in the HPI? I only can count 3 for this new patient? Am I missing anything?
 
Location: Hormonal/Intellectual Disability
Context: Care center while under the care of staff members
Quality: abnormal and aggressive
Timing: frequently
Associated Signs/Symptoms: groping care givers
 
I am a new coder. I was told not to count a Location when pt has diabetes for example. So in this case there is no Location. Quality and Severity-intellectual, abnormal, aggressive. Good catch on Timing-frequently, I agree. Context- all about this problem, all that surrounds it( groping nurses, concerns). Associated signs I think will be patient has no voiding difficulties ( in our E/M PPP we can use ROS for associated signs)
 
Top