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Where is the HPI?

  1. #1
    Question Where is the HPI?
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    I am having trouble "scoring" this cardiac consult (well, office visit since it is Medicare) He has chronic conditions, but he does not document their status. Please help. The report is quite lengthy so I'll abbreviate. Thank You!!!

    INDICATION: Surgical Clearance
    HISTORY: Pt scheduled for left nephrectomy on 1/26/2010. Hx of HTN, non-insulin-dependent DM, CABG three times in 1995. Bladder tumor resection in 2002. Last month kidney mass was found. Denies hematuria, flank pain and fever. No chest pain on exertion. Activity limitied due to intermittent claudication. admists to dyspnea on mild exertion. has productive cough, clear mucous.

    Then the cardiologist documents social history, family history, meds. Physicial exam, review of Chest xray and stress test.

    IMPRESSIONS: CAD, S/P CABG, HTN, non-insulin dependent DM, PAD, COPD.

    ASSESSMENT: ADENOSINE-INDUCED ANGINAL SYMPTOMS, MANIFESTED BY PAIN IN BOTH JAWS. ANGINA IS REMINISCENT OF PRE-CORONARY REVASCULARIZATION. Ekg SHOWS EVIDENCE OF OLD ANTERIOR WALL MI AND IS COROBORATED BY THE MYOCARDIAL PERFUSION SCAN. DEMONSTRATION OF REVERSIBLE ISCHEMIA IN THE DISTAL ANTEROSEPTAL AND APICAL SEGMENTS INDICATES AGRESSIVE DISEASE IN THE DISTRIBUTION OF THE LEFT ANTERIOR DESCENDING ARTERY.

  2. #2
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    INDICATION: Surgical Clearance Chief complaint
    HISTORY: Pt scheduled for left nephrectomy Location on 1/26/2010. Hx of HTN, non-insulin-dependent DM, CABG three times in 1995. Bladder tumor resection in 2002. Last month Duration kidney mass Quality was found. Denies hematuria, flank pain and fever Associated Signs and Symptoms. No chest pain on exertion. Activity limitied due to intermittent claudication. admists to dyspnea on mild exertion. has productive cough, clear mucous.


    I got 4 elements as highligted above.

    Laura, CPC, CPMA, CEMC

  3. #3
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    Oh, Thank you !!! I get it now. I was stumped because the reason for visit was surgical clearance and was like - where are the symptoms?? So for a surgical clearance consult, I would choose the elements that are related to the surgery that patient is scheduled for. THank you so much. ( I don't do a lot of these)
    Debby

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