How would this HPI be audited, using elements or status of conditions?
HPI:
Patient presents with his mother. 1 year 1 month age old patient is here for following up from hospitalization for pneumonia and hepatitis. Mom reports that he is breathing much better, eating much better, and is much more active. He is tolerating the breathing treatments well.
Review of all labs at XXX showed a normal, unimmunized hepatitis panel, as well as no evidence of EBV or CMV.
ROS:
See HPI.
Past medical history, family history, and social history reviewed. Mom denies any recent changes, such as a new food or pet.
HPI:
Patient presents with his mother. 1 year 1 month age old patient is here for following up from hospitalization for pneumonia and hepatitis. Mom reports that he is breathing much better, eating much better, and is much more active. He is tolerating the breathing treatments well.
Review of all labs at XXX showed a normal, unimmunized hepatitis panel, as well as no evidence of EBV or CMV.
ROS:
See HPI.
Past medical history, family history, and social history reviewed. Mom denies any recent changes, such as a new food or pet.