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Wiki HPI: No new complaints

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Tonyj

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CC: Follow up.

HISTORY OF PRESENT ILLNESS: The history of present illness is well characterized in my 01/01/2009 note. Subsequent to the last visit, he has had no new complaints.

1st question: How would I score no new complaints under HPI elements; Associated Signs & Symptoms?

2nd question: Is (Follow up) sufficient documentation for chief complaint?
 
Tonyj said:
CC: Follow up.

HISTORY OF PRESENT ILLNESS: The history of present illness is well characterized in my 01/01/2009 note. Subsequent to the last visit, he has had no new complaints.

1st question: How would I score no new complaints under HPI elements; Associated Signs & Symptoms?

2nd question: Is (Follow up) sufficient documentation for chief complaint?
Click to expand...

In answer to question 2 - this is not sufficient for chief complaint. The "follow up" note needs to state what is being followed up. Example; Follow up for high blood pressure.

As to question 1 - I believe that you can look at the HPI referenced in the note from the previous visit, but the "no new complaints" means you cannot add anything to what was previously there.

Someone else may have a different take on this.
 
ajs said:
In answer to question 2 - this is not sufficient for chief complaint. The "follow up" note needs to state what is being followed up. Example; Follow up for high blood pressure.

As to question 1 - I believe that you can look at the HPI referenced in the note from the previous visit, but the "no new complaints" means you cannot add anything to what was previously there.

Someone else may have a different take on this.
Click to expand...

I'm in total agreement with the follow up portion. I have my concerns about HPI referenced in previous visit.
 
While I have no "official" source....

I do the same as your suggestion, Tony, and use "no new complaints" as S/S for one HPI element. Patient is stating whatever symptoms she has right now, which are none. Also, in agreement with you and Arlene about "follow up" - needs to state the condition being followed.
 
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