Wiki Hpi requirement for modifying factors

[Melodie32]

Hello,

Does anyone know if a provider states "no otc meds taken" whether or not this can be counted as a modifying factor with in the history? I know stating taking otc meds counts, just not sure if stating not taking any is worth the same.?? Any help would be greatly appreciated!

 

[Chelle-Lynn]

For modifying factor to be valid the item must indicate whether the action taken made the situation better or worse...that is to say did the action modify the condition or illness?

To be able to use over the counter medication taken as a modifying factor, there would need to be a notation on whether or not a change occurred.

Examples

1. Improves with Aspirin (over the counter med)
2. Worse when sitting
3. Better lying down
4. Benadryl taken with no affect

Stating no over the counter medication taken does not modify or change anything so it would not be valid to use in this context.

 

[Melodie32]

Thank you so very much!