Wiki HPI element : Modifying Factor

[samueltc]

Does alleviation or aggravation of treatment tried be documented to count against Modifying factor?

Example:

Patient is a 58-year-old Caucasian female with sore throat, headache, chills and fever for past 3 days. Pain is rated as 5/10 on pain scale. Patient is experiencing dull pain. She tried lozenges yesterday.

Per my understanding, HPI elements are Duration, severity, associated symptoms and quality. Please correct me if I am wrong.

My question here is patient has tried lozenges, however, no relief is documented. Can I count this against modifying factor?

 

[thomas7331]

I would tend to agree with you that as documented, there isn't any information about how this modified the patient's complaint, however I have seen some auditors that would allow it. But most official guidelines do not get down to this level of detail about which answer is right or wrong.

However, you do have location here (throat & head), so you have your four elements here already.

 

[Chelle-Lynn]

To answer your question from our prospective, during an audit we would not allow the modifying factor as the documentation does not state how the lozenges modified the throat pain. We look for better, worse, same, etc type of notation.

Thomas is correct that some auditor will allow for it, but as to the letter of the law, it would need additional notation to be allowed. I would use this as a training example for the provider for future records.

Good catch! For modifying...it needs to state how it was modified.

 

[twizzle]

Modifying factors

To answer your question from our prospective, during an audit we would not allow the modifying factor as the documentation does not state how the lozenges modified the throat pain. We look for better, worse, same, etc type of notation.

Thomas is correct that some auditor will allow for it, but as to the letter of the law, it would need additional notation to be allowed. I would use this as a training example for the provider for future records.

Good catch! For modifying...it needs to state how it was modified.

Agree 100%. As an audit consultant I would not give credit unless 'how' it modified the condition was documented.