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HPI element?

S

solocoder

Expert
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458
Location
springfield, MO
Could "MRI is negative for osteomyelitis" documented in the HPI section be considered an element of HPI? Maybe a pertinent negative under associated signs and symptoms? The MRI result is also copied into the note.
 
It would be best to post the CC, HPI as documented and what led up to the patient coming in with an MRI. The HPI is where the physician can get clarity on what makes a condition better, worse, severity and so forth. The only element that it could fall into would be context, so if you already have that you could not count it again. Post the CC and HPI redacted of course.
 
Actually the entire HPI/interval history is copied and pasted from the previous day except for the MRI information so that is the only thing I might even count.

Patient seen at bedside for follow up. Wound care on the left foot is being performed per nursing staff. Vascular surgery has seen Ms. *** and plans to intervene. MRI is negative for osteomyelitis.
 
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