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Wiki Hpi

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maine4me

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One of my doctors saw a patient for followup of multiple chronic conditions. When the patient arrived at the office there was much discussion about the stress she is under and the signs/symptoms, her recent weight loss, etc. The doctor documented that the patient has lost 30 pounds. Can I count this as severity?
 
I would count it toward associated signs and symptoms, it does not seem to be describing severity ( pain scale for example).
 
It depends

Well, that all depends on the entirety of the chief complaint and HPI. For what problem is the physician seeing the patient?

"lost 30 pounds" might be severity if the problem was "unexplained weight loss" and this figure represented a recent loss. On the other hand "lost 30 pounds" might be ROS if the "problem" was a F/U for high cholesterol and physician was asking about what has happened since last year.

Without seeing the entire history section of this note, I can't tell for certain how or whether to count this phrase.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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