The HPI is a "history" ... explained by the patient on prompting by the physician. This is SUBJECTIVE information that describes the nature of the complaint that brings the patient to the office. For example: How long has it been present? Does anything make it better or worse? How bad is it? What other symptoms go with it?
The exam is a record of the physician's findings on examining the patient. This is OBJECTIVE information. For example: BP 120/82. The lungs are clear to auscultation. Heart is RRR w/o MRG. Abdomen is soft and tender w/o hepatosplenomegaly.
That being said, I've seen physician's record elements of history under the "exam" heading ... so I'd have to see the actual note to tell whether you've been given accurate guidance in this particular case.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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