hkatie
Networker
I'm working up a fairly in depth review of our new EMR's auto-coding feature and would like some feedback on the following history. Something's a little off on the back end of this coding and I'm trying to get an idea of whether or not I'm just being too restrictive, if we have a data entry problem (i.e. scribing,) or if this is a programming problem.
CC: Excessive sun exposure, hair loss
Pt is here for a skin check. The patient is being monitored for excessive sun exposure.
Pt comes in for hair loss of scalp. Tried 5% Rogaine foam; did not like what it did to texture and scalp; hard to apply; now uses 2% nightly only. Hair loss is stable with no significant progression. No itching of scalp.
Thyroid: normal
Meds: lisinopril
PMHX: Double mastectomy for breast ca
FH: no significant hair loss/father bald at age 20/brother bald on top of head.
ROS: A focused review was performed and notable for good general health, up to date on GYN, upt to date on eye exam, no new skin lesions, no rash, no lumps and bumps, and no blood thinners.
Specifically, what would you count for HPI?
Thanks in advance for any and all opinions.
-Katie
CC: Excessive sun exposure, hair loss
Pt is here for a skin check. The patient is being monitored for excessive sun exposure.
Pt comes in for hair loss of scalp. Tried 5% Rogaine foam; did not like what it did to texture and scalp; hard to apply; now uses 2% nightly only. Hair loss is stable with no significant progression. No itching of scalp.
Thyroid: normal
Meds: lisinopril
PMHX: Double mastectomy for breast ca
FH: no significant hair loss/father bald at age 20/brother bald on top of head.
ROS: A focused review was performed and notable for good general health, up to date on GYN, upt to date on eye exam, no new skin lesions, no rash, no lumps and bumps, and no blood thinners.
Specifically, what would you count for HPI?
Thanks in advance for any and all opinions.
-Katie