HPI elements as noted by the physician (rather than as stated by the patient)

[CatchTheWind]

I know this is an old question, but I am drawing a blank:

Does the HPI have to be strictly what the patient tells the physician, or can it include the provider's observations, as well? For example, in describing a skin lesion, does the patient have to state that the lesion looks red and scaley, or can the provider's observation of this fact be included in the HPI?

 

[thomas7331]

The physician's observations are counted toward the exam, not the HPI. HPI, by definition, is 'history' - it's what has happened prior to the encounter, so is the information supplied by the patient. Per the guidelines, the HPI is 'a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present.'

 

[Lyta2000]

Think back to the old SOAP method. HPI is the subjective piece. Exam is the O piece. Objective from the doctor.