Wiki HPI elements

Messages
3
Location
South Chesterfield, VA
Best answers
0
Good afternoon

I have a question in regards to HPI elements for the following example and would appreciate any advise and insight
Established Patient visit
Reason for visit - HIV Followup
Last seen 1.2.2019 CD4 660/30% ,viral load 21 on current meds Dx HIV 2011 . Risk Factor Heterosexual
Patient here for followup of HIV asymptomatic ,monitoring and medication adherence and tolerance to Biktarvy . Pt has no complaints today . No pain
History
Syphilis DX and treated 2015
PNA Dx 2009

My thoughts :

Even though this is an Established patient the Duration of the disease and how the patient got it should be used ( every followup visit for anEstablished patient) . This is the reason for the follow up visit and will remain unchanged . In regards to context , the provider indicates Risk factor . I believe , and please correct me if I am wrong that documentation of Heterosexual , homosexual or blood transfusion indicates how the patient got HIV.

Duration - 2011 date of original Dx
Context - Heterosexual How the disease was transmitted
A/S/S Viral load and CD4 count / asymptomatic
 
You have Modifying Factors since the patient is on medication. Can't speak to the issue of how the patient got the virus but, if the rationale you describe is accurate, I would be comfortable counting it toward Context.
 
Top