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Help with HPI - who has dialysis

  1. #1
    Default Help with HPI - who has dialysis
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    I have an HPI that reads:

    Pt is a 40-year old gentleman who has dialysis Tues, Thurs and Saturday and was out of town for the holidays and was driving back. Unfortunately he was not able to make it to dialysis session, so he missed Tuesday, also Wednesday and then came in on Thursday with shortness of breath to the Emergency Room.

    How many elements do you get? I have 2: Quality (shortness of breath); Assoc Signs & Symptoms (missed dialysis).

    Thanks.

  2. #2
    Default
    Pt is a 40-year old gentleman who has dialysis Tues, Thurs and Saturday(timing) and was out of town for the holidays and was driving back (context). Unfortunately he was not able to make it to dialysis session, so he missed Tuesday (modifying factor), also Wednesday and then came in on Thursday (duration) with shortness of breath(location or associated sign and symptom) to the Emergency Room.

    This is assuming you have a chief complaint somewhere else.

    Just my take on it,

    Laura, CPC, CEMC

  3. #3
    Default
    OMG - Thanks so much Laura. I am just CLUELESS today -- its my first day back from having surgery and it seems like I don't know what I'm doing today.

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Complaint is Shortness of Breath
    I'm hoping the chief complaint is listed elsewhere ... but it seems that the reason he is in the ER today is SOB ...

    I get:
    DURATION (Tuesday, and Wednesday)
    CONTEXT or MODIFYING FACTOR (he missed dialysis)
    LOCATION (inferred from shortness of breath)

    I would not count the fact that he usually has dialysis on Tue, Thur & Sat as timing because I don't think he's in the ER for renal failure, but for SOB.

    ***********

    However, if his chief complaint IS Renal failure, then ...
    MOD FACTOR - dialysis Tue, Thu, Sat
    CONTEXT - missed dialysis
    DURATION - Tuesday & Wednesday
    LOCATION - kidneys (inferred from dialysis)
    ASSOC SIGN - shortness of breath

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Default
    Yes, Tessa -

    He's cc is shortness of breath. So I get three - Duration, Associated Signs and Context.

  6. #6
    Default
    This is the ER visit? I read it as a follow up after the ER visit most likely with the nephrologist. I guess I misunderstood.

    Laura, CPC, CEMC

  7. #7
    Location
    Milwaukee WI
    Posts
    4,466
    Default Helps to be clear
    Laura ... I re-read it with your assumption that it was a follow-up and I can totally see how you got that.

    So much of this E/M business is open to interpretation ... It really helps to have a clear picture of the situation.

    F Tessa Bartels, CPC, CEMC

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