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How many elements do you count

  1. Default How many elements do you count
    Medical Coding Books
    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. Default
    Is this just for history (past, family, social)? Or do you mean History of Present Illness?



  3. Default
    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
    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. Default
    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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