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Location of status of 3 chronic conditions in note

  1. Default Location of status of 3 chronic conditions in note
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    Does anyone have any good reference material regarding the status of 3 chronic conditions for the HPI? I am looking for anything that says it has to be part of the History or it can be anywhere in the note? I was under the impression it can be anywhere in the note, including the assessment. I can't find a reference for that. Many of the providers I am reviewing list it in the assessment and my client says they don't count it unless it's listed in the history section of the note.

    I hope this makes sense, been a long day.


  2. #2
    3 chronic conditions are in place of HPI elements. It has to be in the HPI, not the A&P. The 97 guidelines are clear this is where it belongs.

    "An extended HPI consists of at least four elements of the HPI or the status of at least
    three chronic or inactive conditions.
    !DG: The medical record should describe at least four elements of the present
    illness (HPI), or the status of at least three chronic or inactive

    These are history elements and should be in the patients words, when the same info is in the A&P it is in the physicians words.

    Example: HPI "hyperlipidemia-patient states changed eating habits and is exercising, is taking meds faithfully"

    A&P "hyperlipidemia- labs still not at an acceptable level, will increase meds"

    Hope this helps,

    Laura, CPC, CEMC

  3. #3
    I agree.

    Even if it's in the A&P though, it could possibly help towards "RISK" for Medical Decision Making.

    So your HPI - you have "hyperlipidemia"

    On the plan - he states "hypertension and hyperlipidemia, ordering labs to check levels, no issues to report"

    Hypertension wouldn't count towards your HPI but would for RISK. "2 stable chronic illnesses"

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