new coder needs help with HPI

ggparker14

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cc: nausea and vomiting and dehydration.

Patient denies any sick contacts or recent travel. She has had no fevers, chills or diarrhea. patient had a normal bowel movement last night.

How many elements could I use from this?

Any help is appreciated. Thank you.
 
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6
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Hpi

I would give only two - associated signs and symptoms and location. What othe opinions have you received? How many did you count?
 
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who documented the CC? If it was not the MD you can't count it in the HPI.

I see 4 here in what is documented. Context, timing, Associated, and Modifying factors.
 
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Milwaukee WI
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4 or more

Vomiting and dehydration are NOT context ...

Denies sick contacts or travel - CONTEXT
No fever, chills, diarrhea - ASSOC SIGN
Normal - QUALITY
Bowel Movement - LOCATION
Last Night - DURATION

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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