Wiki HPI elements- help

[SHobbs]

Can anyone offer their expertise on this? I come up with 2 elements for this HPI.


HPI:
Patient here for a hospital follow up for leaned over into trash can and when he stood up, he collapsed to the ground. Did not lose consciousness. Evaluated and sent for heart test when patient reports was negative.

 

[hewitt]

Is this verbatim? Not a very good accounting of things. If this is all that's in the note, or a direct quotation from the note, then, I see two as well; context and associated signs and symptoms. If you want to push the envelope a bit, you may be able to use no LOC as quality. Before arguing that you cannot, please review what qualifies as quality....

 

[SHobbs]

yes, unfortunately this is verbatim, I would not have thought to use that as quality, thanks!

 

[kforrest]

yes, unfortunately this is verbatim, I would not have thought to use that as quality, thanks!

I agree

 

[FTessaBartels]

Just two

I would not use LOC as quality ... it's definitely Associated signs/symptoms.


Hope that helps.

F Tessa Bartels, CPC, CEMC