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ggparker14

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Can anyone else give me their opinion on number of elements in this HPI?

HPI reads: Patient presents to ED after receiving a call from her family physician. Had CBC drawn in office today at her follow-up visit which demonstrated that her platelets are only 2K. Patient says she "feels fine" and denies any complaints. She specifically denies any bleeding, easy bruising, or petechiae.

Thanks for any help.
 
3 elements

I see three elements
Context - got call from physician / CBC drawn in office
Severity - platelets measure 2K
Assoc signs/sympt - no bleeding, etc


Hope that helps.

F Tessa Bartels, CPC, CEMC
 
(extracted from saved notes on the subject of timing)

TIMING refers to whether there is a pattern or cycle of the symptom/complaint "continuous", "intermittent", night-time".

Doesn't appear to be such an indication in the note, so I would say that "timing" is not present here.
 
According to an AAPC-certified instructor, "timing" would be considered with the following questions:
When did the problem start?
What is the chronology?
Is it worse after meals?
Does it improve as the day goes on?
"Duration" would be considered with the following:
How long have you had this problem?
How long does the pain last?
Therefore, I would consider "today" as satisfying the "timing" element.
 
NOT timing

I disagree ...

The patient is here "today" for a follow-up visit. This has nothing to do with the timing of the complaint.

Hope that helps

F Tessa Bartels, CPC, CEMC
 
rhblevins61@yahoo.com said:
Can anyone else give me their opinion on number of elements in this HPI?

HPI reads: Patient presents to ED after receiving a call from her family physician. Had CBC drawn in office today at her follow-up visit which demonstrated that her platelets are only 2K. Patient says she "feels fine" and denies any complaints. She specifically denies any bleeding, easy bruising, or petechiae.

Thanks for any help.
Click to expand...

Patient went to the ER after they had labs drawn in the office. It did not say they were at the ED for a follow up..dictation stated that patient was at family physician for follow up.
 
How is
When did the problem start?

different from
How long have you had this problem?

In the example the answer is the same..today.


Neither of these are timing.


Dee
CPC,CPMA, CPCD
 
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