Wiki HPI Help?

[DNUNNERY]

Would the following HPI be counted as brief or extended?

"Here as new patient to discuss 2-3 mo history of fatigue and decreased energy. Has knot in right breast which she noticed last wk, has h/o of goiter but no recent labs. Has GERD that Omynazole is working fairly well for."

 

[margsablan]

Hpi

Brief and Extended HPI are distinguished by the amount of detail needed to accurately characterized the clinical problem(s). Brief HPI consists of one to three elements and an exteded HPI consist of four or more elements. HPI is the reason or the cause why she is at the clinic (medical necessity). Did the pt came for history of fatigue and decrease in energy, if so you have duration (2-3 mos), quality (fatigue) and associated sign /symptom (decrease of energy) you have three elements and that will make it BRIEF. The word HISTORY describing fatigue may throw you of, so check that out.
Did she came to have the knot in the right breast check. In that case you have the location (breast), duration (last week) and no mention of severity quality, etc so there are two elements present. In my opinion in the absent of other info your HPI is still BRIEF. It will be different if you can document other elements.

margie.

 

[sbicknell]

Here as new patient to discuss 2-3 mo history of fatigue and decreased energy. Has knot in right breast which she noticed last wk, has h/o of goiter but no recent labs. Has GERD that Omynazole is working fairly well for

CC: fatigue
HPI:
2-3 months- duration
decreased energy- assoc S&S

Problem is the patient comes in with 2 acute problems and 2 chronic (maybe) but he doesnt give any info on any of them. Very poor HPI.

Acute: fatigue and knot in breast
Chronic: GERD and possibly the goiter but unclear if goiter is an active still under monitoring and treatement or is a resolved/past history.

Either way, he is only getting a brief HPI out from this

 

[DNUNNERY]

Thanks for your input. I am having problems getting our providers to document enough info in HPI. They are missing some much needed reimbursement on new patients. Their exams and MDM are usually at a higher level than the history supports. Very frustrating.