Hpi-Modifying Factors

pattytpa

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A new patient, John Smith, comes into my office for an evaluation following a motor vehicle accident that occurred on 1/3/02. His chief complaints consist of left-sided neck pain and left anterior chest wall pain. The neck and chest pain started a few hours after the accident. The neck pain sometimes radiates into the shoulder and can be sharp in nature. The pain decreases with the use of the heating pad.

I say the following are each included in the above HPI descriptors?
Location
Quality
Timing
Context
Modifying Factors

The book said context was not in the progress note. What do you think?
 

dmaec

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A new patient, John Smith, comes into my office for an evaluation following a motor vehicle accident that occurred on 1/3/02. His chief complaints consist of left-sided neck pain and left anterior chest wall pain. The neck and chest pain started a few hours after the accident. The neck pain sometimes radiates into the shoulder and can be sharp in nature. The pain decreases with the use of the heating pad.

I say the following are each included in the above HPI descriptors?
Location
Quality
Timing
Context
Modifying Factors

The book said context was not in the progress note. What do you think?
I see"
CC/Location = pain (neck/chest)
Timing = few hours after accident
Severity = sharp in nature
Modifying Factors = paint decreases with use of heating pad

I don't see Quality (unless that's what I'm calling Severity) ;) and I don't see Context either.
what do you see as Context?

Thanks!
 

pattytpa

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I thought "following a motor vehicle accident that occurred on 1/3/02" would constitute as "context". I gave quality for "sharp in nature"
Thanks a bunch for the reply.
 
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I agree

I agree with your assessment that "context" is documented based on the documentation that it follows the accident and I agree with "quality" instead of severity. When dealing with pain, I typically judge "severity" on the 10 scale.
 

dmaec

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yes, I see the comparison with the "severity"/"quality" - and I'd agree, "sharp" should go under quality. however - I still don't see "context" here. Context is basically - under what circumstances does it occur - which I believe is referring to the CC/issue at hand (eg, the sharp pain only happens when bending to the right - or some other statement to that effect).
 
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