MnTwins29
True Blue
One of our physicians is disputing my findings on one of her records because of an HPI element. This would make the difference between 3 or 4 elements to give an increase in the level of history.
On the HPI for knee pain, it is documented that the pain is "constant, worse at night." I say this statement can be used for timing. The physician says that she can use it for timing (constant) and for modifying factors (worse at night). I maintain that statement can't be a modifying factor because the patient can't control that - night time is going to come, no matter what the patient does!
Thoughts?
On the HPI for knee pain, it is documented that the pain is "constant, worse at night." I say this statement can be used for timing. The physician says that she can use it for timing (constant) and for modifying factors (worse at night). I maintain that statement can't be a modifying factor because the patient can't control that - night time is going to come, no matter what the patient does!
Thoughts?
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