Wiki HPI Elements

JJOHN0312

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Where would you count "chronic" or "acute" conditions in the History of Present Illness Section? Under Severity or Quality??
 
I would not count either of these as an HPI elements, because these are not terms that describe a history of a patient complaint - those are terms that a provider uses to assess a conditions. Remember that the HPI is the subjective description of the complaint given by the patient. If you see these in an HPI, it is usually provider's documentation of the status of an existing condition, not an HPI. I suppose that if the patient is saying 'my cough is chronic', for example, this could be considered duration, but you don't usually find a patient describing their own illness as being acute or chronic.
 
Ok, so are you saying that the HPI elements should only be used if it is in the patient's own words?? I was thinking the chief complaint was mostly in the patient's words. But then the provider describes the HPI in their own words?
 
The HPI does not have to be in the patient's words, but as I understand it, it is the subjective information that the doctor documents based on their interview with the patient or other person - the "chronological description of the development of the patient's present illness from the first sign and/or symptom, or from the previous encounter to the present". If the provider is documenting a diagnosed existing condition rather than the progress of an illness as related by the patient, I would consider that a status. Either way, I don't think auditor is going to penalize you for counting 'chronic' or 'acute' as an element. Remember these are guidelines, not regulations, so there is room for different interpretations.
 
HPI is information from the patient, as mentioned, an interview process and "paint the picture" of the reason for the visit. It's the "listening" portion of the encounter and can be very subjective. A "timing" element for one auditor, could mean "context" to the next. So as long as your practice/organization identifies and credits each element consistently, and follows the process and guidelines, it's good practice and providers will find it easy too.
 
member that the HPI is the subjective description of the complaint given by the patient. If you see these in an HPI, it is usually provider's documentation of the status of an existing condition, not an HPI. I suppose that if the patient is saying 'my co


I think we can consider as quality as it describes the nature of condition.
 
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