Wiki Hpi-subsequent inpatient

solocoder

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Is there anything here that I can call HPI? This is a subsequent inpatient visit.

S: Patient seen at bedside today. She has no new complaints. Patient denies nausea, vomiting, diarrhea, fever, chills, shortness of breath, calf pain or chest pain

Thanks.
 
What's the chief complaint?

What's the chief complaint? Why is the patient in the hospital?

Subsequent hospital visits required an INTERVAL history (not quite the same as an HPI) - i.e. what has happened since the last visit.

So, IF the patient is hospitalized because of SOB ... you could count the denial of shortness of breath or chest pain as location and associated symptom, and count the rest as ROS.

If the patient was hospitalized because of some other problem, totally unrelated in any way to the list of denied symptoms, then you're right, you have no interval history (or HPI).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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