Wiki Negative Response for HPI Elements

[JParker5]

Hi,

I know this question has been asked in the forum but I wanted to see if there was any difference in opinion now. Can we use Negative response for HPI elements? Such as negative for trauma or patient hasn't take any medication. If anyone has any guidelines to support, it would be greatly appreciated.

Thank You

 

[kdlberg]

Negative responses count when they are pertinent to the chief complaint. For instance, if a patient is having abdominal cramping and the HPI includes "denies vomiting and diarrhea," that can count towards the HPI. But if a patient has a sprained ankle, then "denies vomiting" isn't relevant to the chief complaint.

Official guideline from CPT Assistant, April 1996

"A clinician's impressions formulated during the interview may lead to questioning about additional sensations or feelings. Examples may include: diaphoresis (marked sweating) associated with indigestion or chest pain; tremulousness; weakness and hunger pangs in patients with diabetes; or blurring vision accompanying a headache. Generalized symptoms, such as chills and/or fever (and its levels) headaches, overall weakness, or exhaustion are often relevant. A clinician may ask patients directly about "pertinent positives and negatives," such as the presence of bloody or tarry stools associated with changing bowel habits."