Wiki HPI elements

Dunellon, FL
Best answers
I need an outside opinion. I coded a laceration patient with a cut that bled than stopped and began bleeding again. I counted bleeding as a quality of the cut. The cut as the location. being able to walk without pain as the severity and a plate falling on the foot as context. To get a comprehensive HPI. Is this correct? The coders that audited this chart are saying bleeding is not a quality of the cut, but agree with the rest. Thank you.
Actually, I personally would count the bleeding as positive associated signs and symptoms. I'd also code the being able to walk without pain as a pertinent negative ROS or as negative associated signs and symptoms in the HPI.

This doesn't sound like a comprehensive HPI, to me. Just my humble opinion.
Seems borderline for brief on the HPI. You could make a case for greater than 4 elements. One would need to see the actual note.

If this HPI is brief and you came up with comprehensive for the History then your PSFH and ROS must've been scored very highly.
I would not count "plate falling on foot" as context. To me that is the external cause of the injury (the S code), not the context. I see the context as being that the patient was inebriated, has Parkinson's Disease or impaired vision, he was washing dishes and his hands were wet, or even that he was just walking to the table and the plate slipped out of his hand for no reason.

Please correct me if I'm wrong!
Context is a variety of things, but the one constant is it's either when the problem happens (while walking, sitting, eating, etc...) or how the problem happened, or what brought the patient to this visit...

The basic definition of context is:

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  • the circumstances that form the setting for an event, statement, or idea, and in terms of which it can be fully understood and assessed.

Also, page 2 of HCCA Audit Manual for Evaluation and Management Services, has some great information on HPI elements. You can find that here: Manual.pdf

Where at context, it reads, "Context: It’s the one descriptor that has given auditors the most trouble. Look for statementsthat describe how a complaint occurred such as: “Injuries incurred in a motor vehicle accident”,“running down the steps”, sitting in a chair”, “playing sports”, etc."

I hope that helps :)