I have a provider that documented 'Patient was seen on XX/XX/XXXX...' and my EMR system is calculating that as duration. My question is: is that appropriate? I know that typically a time frame of when the problem started should be documented in order to count as duration. My co-workers and I had an open discussion about this and we have mixed opinions. Am I overthinking this? Any advice would be appreciated!
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Wiki Question on HPI factor-duration
- Thread starter cheryl.vanklingeren
- Start date
thomas7331
Guest
The HPI, by definition, is "a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present". "Patient was seen" does not describe the illness or symptom in any way, and in my opinion does not meet the definition of an HPI element. The duration element should give information as to how long the patient has been experiencing the problem, not when they were seen by a provider. If there is additional information as to what occurred at that visit and how it affected the patient's problem, then that might count towards HPI elements, but just the date the visit alone is not sufficient in my opinion.
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Pathos
True Blue
Agreed, the patient might have been seen by the provider for something completely unrelated to the problem being dealt with in the current note. CMS gives us only one example of Duration (example: started 3 days ago), which directly describes when the problem started. A simple date stamp in the note does not explain when the problem began at all, unless additional documentation can show a direct link with the problem and that date (ie. Patient was seen on 1/1/1901, when their symptoms started flaring up...).
The problem was established at the prior visit and a prescription given at that time (which is all listed on the current note). Would you still not count that?
Pathos
True Blue
Every note should be able to stand on it's own proverbial legs. If the current note does not reference a direct link to the date and the problem, then I would be hesitant to count the date towards any parts of the HPI.
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Right, thanks for the input! 