South Chesterfield, VA
Best answers
Good afternoon

I have a question in regards to HPI elements for the following example and would appreciate any advise and insight
Established Patient visit
Reason for visit - HIV Followup
Last seen 1.2.2019 CD4 660/30% ,viral load 21 on current meds Dx HIV 2011 . Risk Factor Heterosexual
Patient here for followup of HIV asymptomatic ,monitoring and medication adherence and tolerance to Biktarvy . Pt has no complaints today . No pain
Syphilis DX and treated 2015
PNA Dx 2009

My thoughts :

Even though this is an Established patient the Duration of the disease and how the patient got it should be used ( every followup visit for an Established patient) . This is the reason for the follow up visit and will remain unchanged . In regards to context , the provider indicates Risk factor . I believe , and please correct me if I am wrong that documentation of Heterosexual , homosexual or blood transfusion indicates how the patient got HIV.

Duration - 2011 date of original Dx
Context - Heterosexual How the disease was transmitted
A/S/S Viral load and CD4 count / asymptomatic