Opinions on HPI please

MandyFlagg

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Hi
I was wondering if anyone could tell me what elements they would pull from the following HPI.

Pt has a history of bladder cancer, transitional cell, advanced initially treated with Gemzar, carbo, Taxol, and had surgery done and there was residual small cell component. She had four cycles of adjuvant carbo, VP-16 but now has recurrent disease a year or two later with mets to the lung and abdomen. She initially was reinduced with carbo, VP-16 but appears to have progressed and was changed to VP-16, Taxol. She is handling chemo pretty well and had recently had a stent changed.

Thanks
 
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Hpi?

Well, this doesn't look much like an HPI to me ... it looks more like a past medical history, with perhaps some ROS.

What's the chief complaint?

F Tessa Bartels, CPC, CEMC
 

OCD_coder

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I had this very same problem with the oncologists I work for. I had to remind them that the HPI is the information we gather directly from the patient when we ask them questions about their condition.

This is a past medical history documentation. It's hard to tell what kind of a physician the patient is seeing the primary care physician or their oncologist in this note.

I do agree it appears to be a chemo-followup. Nothing in the HPI appears to be information obtained from the patient, but a summary of medical treatment.

Possibilities:
recurrent= Timing
history of bladder cancer= Location
treated with= modifying factor
 
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HPI for chemo follow-up

This is NOT my are of expertise ... but ...

I would think an HPI for a chemo therapy follow-up visit would be something like:
Patient here for follow-up of chemotherapy, which began mm/dd/yy. She has had some mild nausea, especially the day after infusion. XYZ drug has been helpful in controlling this.

So with above you have duration (mm/dd/yy), assoc sign (nausea), severity (mild), context (day after infusion) and modifying factor (XYZ drug).

AGAIN .. This is NOT my area of expertise and I am writing this just off the top of my head. May be totally out of the realm of reason, but I'm just trying to illustrate what an HPI would look like.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

MandyFlagg

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I have been working with them, explaining the exact same information but I was just going roung and round with auditors about these notes that are from 2006. Great idea's though! Thank you for your help!
 
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