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Wiki HPI Elements-What HPI elements

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klthompson

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What HPI elements can be found in the following chart note?

"History of Present Illness
:
pt sent here to discuss surgical removal of endoscopically unresectable hepatic flexure polyp. This was just a screening colonoscopy. He has had minimal left abd. pain since colonscopy. No blood in stool. Patholgy results reviewed with pt and his wife at this time. "

Thanks for your thoughts and help.
 
At first glance...

I see three: Location (left abdomen), Quality (minimal), and duration (...since colonoscopy, as long as the date of this is documented somewhere).
 
the date of the colonoscopy is listed in the Chief Complaint of the note, but the nurse documents the CC, can I still use it? Also can the colon polyps listed in the HPI be used for anything?
 
there are only 4 HPI in the text

left abdomen - location

minimal pain - severity/quality

since colonoscopy - can be considered as context and not the duration

no blood in stool - associated sign and symptom


abhishek:D
 
I agree with 4 hpi's.

Location, duration (..since colonoscopy), severity or quality (minimal pain), assoc signs (no blood in stool).

This is an ideal visit to bill based on time instead of elements, if time was documented.
 
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