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Thread: How many elements do you count

  1. #1

    Default How many elements do you count

    AAPC: Back to School
    I would like opinions regarding History bullets you count

    78 yr old who fell at home. She was getting out of bed to go to bathroom with a syndopal episode. She fell hitting the face. She complains of pain between the shoulders and face. She sustained a rib laceration and nasal abrasion. She is amnestic to the fall.

    Thanks in advance

  2. #2


    Is this just for history (past, family, social)? Or do you mean History of Present Illness?



  3. #3


    I see context (for the fall)..

    Location (shoulders)

    Quality (pain, could you severity if it showed severity of the pain)

    Associated Signs and Symptoms (laceration)

    Any other opinions?


  4. #4


    I see...
    context (feel getting out bed)

    Location (shoulder)

    Associated Signs and Symptoms (laceration)

    I would not use pain as quality usually to use quality it would be (sharp/dull/throbbing ect)

    So I believe there are 3 elements in this HPI
    Robin Ingalls-Fitzgerald cpc,cemc,ccs,fcs

  5. #5
    Join Date
    Apr 2007
    Milwaukee WI

    Default Hpi

    I'm assuming that you have a separate chief complaint ... and that this is just HPI.

    I see:
    Context - getting out of bed w/ syncopal episode
    Assoc signs - pain, amnesiac to fall
    Quality - laceration & abrasion
    Location - shoulder, face, rib, nose

    Too bad the doctor didn't tell us WHEN she fell ... you'd have duration.

    F Tessa Bartels, CPC, CEMC

  6. #6


    What if there is no separate CC? Would you infer from the HPI that the CC was a head, shoulder, face problem and then count all the HPI elements within the statement?

    Just wondering...

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