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Wiki side effects - which E&M element?

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karlam

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I am stumped...as usual. A patient comes in for a routine follow-up to check HTN, hyperlipidemia, and/or diabetes. The physician states that the patient has been taking the medications as prescribed without side effects. Which element would this be?

Thanks for any suggestions anyone may have!
:confused:
 
I would say modifying factor, but keep in mind that as long as they give the status of 3 chronic conditions (HtN, hyperlipidemia, diabetes) that constitutes an extended HPI.
 
Thanks! I was thinking modifying factors, as well. Unfortunately, the documentation doesn't support the status of 3 chronic conditions. As with most family practices, many of our patients only have one or two conditions.
 
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