Wiki new coder needs help with HPI

[ggparker14]

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.

 

[deon lartigue]

Hpi

I would give only two - associated signs and symptoms and location. What othe opinions have you received? How many did you count?

 

[ivorytofu@hotmail.com]

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.

 

[FTessaBartels]

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

 

[jnewberry]

I see four..........

associated s & s
modifiying factor
quality
timing