HPI statement "Patient Feels Fine"

ollielooya

True Blue
Messages
900
Location
Everett, WA
Best answers
0
Does this statement qualify for quality as an element in HPI? I think not, but in reading a descriptor as "what kind", sharp, dull staiing, burning, irritating, throbbing, aching constantly, intermittent---the fact that the patient is devoid of these makes me wonder if "patient feels fine"could be plugged in. Might be a case of my "over-thinking" again. I know this has been addressed on the forum before, but couldn't pull it up.
 

LindaEV

Expert
Local Chapter Officer
Messages
438
Location
Kansas City, MO
Best answers
0
I'm curious what the cheif complaint is...and if the patient feels fine what the purpose of the visit is. If it is a follow up to something, and that was all i had, I would give 1 HPI element of quality.
 
Messages
4,466
Location
Milwaukee WI
Best answers
0
I tend not to count this

First, I work in pediatrics, and more specifically with pediatric surgeons. We only see patients who have some definitive, potentially surgical, problem.

That being said, I usually don't count such nebulous statements for any of the HPI elements.
What would I count as quality? Let's look as specifics rather than generalities ...
Complaint F/U fracture - open vs closed or "greenstick"
complaint DM - type 1 or type 2, controlled or uncontrolled
Complaint hernia - reducible or incarcerated or strangulated
Complaint rash - red, itchy, patchy, scaly

However, I think LindaEV has a valid point. If I could be persuaded to count is as a "negative" report, I might count it as negative for assoc signs/symptoms.
If the patient is coming in for a F/U of DM2, for example, and the only HPI is "patient feels fine" then I think it might count for quality. Still, if you're only going to get ONE HPI element, I'd rather see duration .... e.g. Last seen 2-13-12, and patient feels fine.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

ollielooya

True Blue
Messages
900
Location
Everett, WA
Best answers
0
further clarification to one of your posts?

However, I think LindaEV has a valid point. If I could be persuaded to count is as a "negative" report, I might count it as negative for assoc signs/symptoms.
F Tessa Bartels, CPC, CEMC
Please, Tess can you elaborate and/or furnish an example to the "negative report" aspect?
I took the liberty to bold and underline the part in question.
 

Tonyj

True Blue
Messages
644
Location
Lithonia, GA
Best answers
0
Please, Tess can you elaborate and/or furnish an example to the "negative report" aspect?
I took the liberty to bold and underline the part in question.
I would count it as 1 point for severity. See below "coding tool for history" I've attached the link.
Severity; Intensity, degree or measure of a symptom. On a scale of 1-10, how severe is the pain? Ex: mild pain, fever 101, my blood sugar is 175, feels well, no complaints, worse pain I've ever had.

http://www.codingbuzz.com/forms.html
http://www.professionalcodingservices.com/
 
Messages
4,466
Location
Milwaukee WI
Best answers
0
I count negatives

I could negatives ("patient denies" or "no x, y, z") as associated signs/symptoms.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

natraj21

Contributor
Messages
24
Location
E/M
Best answers
0
I could negatives ("patient denies" or "no x, y, z") as associated signs/symptoms.

Hope that helps.

F Tessa Bartels, CPC, CEMC
Hi,

How should be the associated signs and symptoms?
should it be related to cheif complaints related system or anything other than that?
Eg: Pt came with headache and he has palpitation, there is no trauma or injury..

in this case can we consider palpitation as associated sign.

Thanks in advance

Natarajan Chellamuthu, CPC.
 
Top