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Wiki Opinion on HPI

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dballard2004

dballard2004

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I am auditing a chart for orthopaedics/sports medicine and I need a second opinion on the HPI, please.

The chart says the following: "The patient is a 25-year old male who was playing basketball about two weeks ago and went down hard. The patient got an injury to his right knee. He did not trust it and felt that his knee gave out from underneath him."

I come up with:

Location=right knee
Duration=two weeks
Context=went down hard


Am I missing any?

Thanks.
 
Last edited:
Ah, you're looking for that elusive fourth component, and my assessment mirrors that of your own. Can we really extract any additional components from the statement, "He did not trust it and felt that his knee gave out from underneath him?" From my perspective I just can't see anything additional, but hope others will jump in here and comment. ---Suzanne E. Byrum CPC
 
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