Wiki HPI 'matching' assessment

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Petlorilea

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I have coders who are overflagging providers 'after the fact'. I posted an example on another thread and got great feedback, but I have another. And its RAMPANT. The problem is the coders want to have the providers amend the chart to include all things assessed in the HPI (not the other way around...I agree what you present for is what should be assessed).
Patient presents with headaches and hypertension. In the assessment, those diagnoses are documented, but there is also mention of urinary frequency. Provider writes rx. Patients do this a lot (I've even done it to my dr), but many of the staff want the HPI to be amended to match the A/P, even if it reads 'since you're writing a script for my BP, that reminds me that I'm also out of insulin', or 'does this mole look odd to you?'
I keep trying to tell them that this has the potential for overcoding, and I'm pretty much getting laughed out of the facility.
I promise I won't ask again! Thanks
 
I have seen items in the assessment that were not in the HPI, but the physician found during the exam. The mole is a great example - the patient may not have thought to mention it, but the physician found it while inspecting the skin and documents it, then adds a plan for treatment. What's the problem with that? Just because the PATIENT didn't mention it doesn't mean there is a problem with the physician treating it. I agree with you - sounds like an attempt to create more HPI elements to increase the level.
 
Thank you Lance!
What about when the patient DOES mention it, but at the end of the visit? I still don't think the HPI should be amended. These questions are not in my CEMC study, and if I'm not on the right track I feel I should not continue in this field
 
you are correct, The HPI is what the patient marks down or utters to the MA or nurse, and is then transferred by the provider and the patient is asked for their agreement. However once the provider is with the patient and performing the exam, anything and everything can and will come up, some things are discovered by the provider like a breast lump, other things the patient had to get up the courage to bring up and can happen later in the visit such as ED. These do not get amended to the HPI as they were not discussed with the patient prior to the exam as a history issue.
 
Another thought on this is that there is no requirement that the elements of the HPI be in a designated section of the documentation. Though use of labeled fields makes it easier for coders and chart reviewers, it is not a mandated format and it is the responsibility of the coder/reviewer to look at the entire note and put the information into the correct context. As noted, patients do not follow a specific format in how they present themselves and often bring up questions or concerns in the course of an encounter or have problems they have not even recognized.
 
One other thought

Just want to add to the good advice. I could be wrong but it also looks like the providers don't want to play the HPI game. I often see multiple symptoms or problems, but not necessarily the necessary HPI elements. So in your case with a headache wouldn't it be good medicine for the provider to ask how much does it hurt (severity); how long has it hurt (duration) what helps (modifying factor). You already have location as in head. Sometimes the issue is not over or under documentation or coding but provider stubborness.

Jim S.
 
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