Tools for documenting HPI

dclark7

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Hi everyone,
My docs are looking for some type of tool they can use to help them remember what they need to document for HPI. We have medicare's E/M Documentation Auditors' Instructions, but this doesn't really help them. I figured rather than reinventing the wheel I'd see if anyone has something they use. Thanks.

Doreen, CPC
 

dclark7

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Thanks, at least I have someplace to start. I don't know why they have such a problem with the HPI, but this seems to be their weakest area of documentation.

Doreen
 
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Hpi

History of Present Illness has 8 elements, as follows:

Location - "where" - site, diffuse or localized
Quality - "what kind" - sharp, dull, constant, intermittent, improved, worse
Severity - "how bad is it" - pain scale 1-10, mild or severe
Duration - "how long" - length of time it has been present
Timing - "Is there a pattern" - relation ot something else, continuous or repetitive
Context - "what brings it on" - does it occur with a specific activity?
Modifying factors - "what makes it better or worse" - prior treatments or medications tried, worse w/ exercise, better with heat
Assoc Signs & Symptoms - "what comes with it" - symptoms that accompany the main symptom.

F Tessa Bartels, CPC, CPC-E/M
 

dclark7

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Thansk, Wendy, I replied to your message. As for the 8 elements, I have explained in every way I can think of what needs to be document. The doc I work for seem to do better with visual aids.

Doreen, CPC
 
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Examples help

Doreen,
Maybe an example will help:

Patient fell off swing yesterday, and noted immediate sharp pain in left wrist. This morning wrist is noticeably swollen and bruised.
Here you have 4 elements of HPI -
Duration - yesterday
Quality - sharp
Location - left wrist
Assoc sign - swollen, bruised

OR ...

Patient with intermittent chest pain for past two days, described as "mild, more like tightness," worse with exercise such as going up stairs
This gives up 5 HPI elements (you only need 4 for highest level)
Timing - intermittent
Location - chest
Duration - two days
Quality - mild
Context - worse w/ exercise


Another thing you could do is take some of the actual HPIs your doc has documented and show how you get only 1 HPI element (for example).

Good luck!

F Tessa Bartels, CPC, CPC-E/M
 
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