If a patient is being seen for multiple issues, can you combine elements of the HPI to get an extended HPI? Here's what's documented:
Chief Complaint:
1. Right sided pneumonia.
2. Left decreased hearing.
Dictated HPI
Subjective: The patient arrives here today for followup with medical problems. Since this last appointment she has been to the ER diagnosed with right sided pneumonia. She has now completed her course of Avelox x7 days. She has had no fever or chills. She continues to cough.
She complains of intermittent loss of hearing on the left side with past history of this and questioning what it might be.
If I separate them, I only have have location, modifying factors & assoc. sign/symptoms for the pneumonia and timing & location for the hearing loss. Can I combine them? Am I missing something I can use? Thanks for any help!
Sue
Chief Complaint:
1. Right sided pneumonia.
2. Left decreased hearing.
Dictated HPI
Subjective: The patient arrives here today for followup with medical problems. Since this last appointment she has been to the ER diagnosed with right sided pneumonia. She has now completed her course of Avelox x7 days. She has had no fever or chills. She continues to cough.
She complains of intermittent loss of hearing on the left side with past history of this and questioning what it might be.
If I separate them, I only have have location, modifying factors & assoc. sign/symptoms for the pneumonia and timing & location for the hearing loss. Can I combine them? Am I missing something I can use? Thanks for any help!
Sue