Wiki HPI Elements or Conditions???

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SHobbs

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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

I would say it can't be status of conditions. As I know it, you count status of CHRONIC/INACTIVE conditions. The two conditions listed are not chronic or inactive. You would need to count bullets and it was really hard for me with the limited info.
 
SHobbs said:
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.
Click to expand...

I am going to try and take a stab at this....

"Breathing much better/ tolerating breathing treatments" could be Modifying Factors & possibly Severity.
"Eating and more active" Associated Signs and symptoms- maybe
 
SHobbs said:
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.
Click to expand...

I believe I can pull 2 HPI elements here.

Tolerating breathing treatments would be modifying factors and severity/quality for breathing much better, eating much better and is more active.
 
Location inferred

Location can be inferred from "pneumonia and hepatitis" (lungs & liver respectively)
Modifying Factors - "breathing treatments" + breathing better
Assoc sympt - eating better
Severity - normal hep panel (this is more of a stretch .... as you will likely count this in the MDM)


By the way ... if doc had simply given us the discharge date from the hospital you would have duration.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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