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Consult and 2 separate HPI paragraphs

  1. #1
    Default Consult and 2 separate HPI paragraphs
    Medical Coding Books
    This group of hospitalists work that I am looking at has me stumped. When they have a consult for medical management or diabetes they always have two paragraphs for HPI. The first paragraph contains the info of how the pt came to be in the hospital. The second paragraph contains information on the medical management issues and/or diabetes. Standing alone, one paragraph does not always come up w/ 4+ elements for HPI and even together sometimes the same elements are captured. Say the first paragraph is painful right foot (location and quality) and the 2nd paragraph is history of uncontrolled diabetes (quality). So does the first paragraph count towards scoring elements?

  2. #2
    Central Pittsburgh
    All of the information they provide can be used toward achieving HPI. The painful foot is associated with the uncontrolled diabetes-they are relavent to the patient and to the history of the current illness. Use it all-it's all information the MD is using for the patient and certainly to help his documentation.

  3. #3
    thanks, just wanted to make sure!

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