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DETAILED HPI ? WHere

  1. #1
    Default DETAILED HPI ? WHere
    Medical Coding Books
    SO much going on here Is this detailed? thanks

    This is a 20-year-old female patient with history of depression, diabetes
    mellitus, who was brought in for weakness. History was obtained from the
    patient's husband, patient, as well as the sister. The sister found her
    lying on the floor this evening. The patient was unable to get up. She
    was not confused. She was just feeling weak. The patient denies any
    focal weakness, tingling or numbness. No headache, blurred vision, or
    double vision. There was no report of any facial droop or any slurred
    speech. As per the sister, the patient appeared very pale and weak. The
    patient could not get up from the floor. Her sister and her sister
    in-law helped her to get up and she was brought here for further
    evaluation. Also she had urinated all over the sofa. The patient has
    had episodes like this where she is incontinence of urine. She also has
    increased urine frequency. The patient denies any fall or any
    light-headedness or syncopal episode. No chest pain. No shortness of
    breath. She denies any hip pain or any back pain. She just feels weak.
    The patient is a very poor historian. She has history of depression as
    per the family. The patient sleeps almost all day. She does not complain
    much. There was no report of any seizures. She does not appear to be
    confused. The patient states she was lying on the floor for about 1 hour,
    but she clearly denies any syncopal episode or any focal weakness. She
    just says she does not know why she was on the floor. She denies any
    fever, chills or cough. No abdominal pain, nausea, vomiting or diarrhea.
    No blood in the stools. No pain with urination or any burning sensation
    with urination. No rash.

  2. #2
    Default
    Yes, I would say this is detailed.

    This is a 20-year-old female patient with history of depression, diabetes
    mellitus, who was brought in for weakness. Chief Complaint.
    History was obtained from the
    patient's husband, patient, as well as the sister. The sister found her
    lying on the floor this evening. The patient was unable to get up. She
    was not confused. She was just feeling weak. Location (general)The patient denies any
    focal weakness, tingling or numbness. No headache, blurred vision, or
    double vision.
    Associated Signs and Symptoms
    There was no report of any facial droop or any slurred
    speech. As per the sister, the patient appeared very pale Quality and weak. The
    patient could not get up from the floor Severity
    . Her sister and her sister
    in-law helped her to get up and she was brought here for further
    evaluation. Also she had urinated all over the sofa. The patient has
    had episodes like this where she is incontinence of urine. She also has
    increased urine frequency. The patient denies any fall or any
    light-headedness or syncopal episode
    Context (pertinent negative)
    . No chest pain. No shortness of
    breath. She denies any hip pain or any back pain. She just feels weak.
    The patient is a very poor historian. She has history of depression as
    per the family. The patient sleeps almost all day. She does not complain
    much. There was no report of any seizures. She does not appear to be
    confused. The patient states she was lying on the floor for about 1 hour, Timing or Duration
    but she clearly denies any syncopal episode or any focal weakness. She
    just says she does not know why she was on the floor. She denies any
    fever, chills or cough. No abdominal pain, nausea, vomiting or diarrhea.
    No blood in the stools. No pain with urination or any burning sensation
    with urination. No rash.

    There are actually probably more, maybe even better than what I picked out, but there are certainly enough to qualify for detailed. You have personal history of depression, etc, social history in that she is married, family history since her sister is alive and with her plus at least 2 ROS.

    Detailed history is covered.

    Laura, CPC, CPMA, CEMC

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Detailed
    I do get 4 elements of HPI out of this. I also get 10 ROS, a Past Med Hx and a Social hx. If you had a family medical history you'd have a comprehensive history. I would not count family history just because sister is alive and with her. Doesn't tell me anything about the sister's medical history that may pertain to this patient. If there was mention of family history (positive OR negative) of depression, DM, stroke or MS THAT would count.

    To try to keep things straight, I'll color code
    Chief Complaint
    HPI - duration, context, assoc symptoms, severity
    ROS - Neuro, Eyes, Constitutional, GU, CV, Respiratory, MS, Psych, GI, skin
    Past Medical and Social history

    This is a 20-year-old female patient with history of depression, diabetes
    mellitus
    , who was brought in for weakness (chief complaint). History was obtained from the
    patient's husband, patient, as well as the sister. The sister found her
    lying on the floor(context) this evening(duration). The patient was unable to get up. She
    was not confused(Assoc sign). She was just feeling weak. The patient denies any focal weakness, tingling or numbness. No headache (neuro), blurred vision(eyes), or
    double vision. There was no report of any facial droop or any slurred
    speech. As per the sister, the patient appeared very (severity) pale and weak. The
    patient could not get up from the floor. Her sister and her sister
    in-law helped her to get up and she was brought here for further
    evaluation. Also she had urinated all over the sofa The patient has
    had episodes like this where she is incontinence of urine. She also has
    increased urine frequency(GU). The patient denies any fall or any
    light-headedness or syncopal episode. No chest pain(CV). No shortness of
    breath(Resp). She denies any hip pain or any back pain(MS). She just feels weak. The patient is a very poor historian. She has history of depression(Psych) as per the family. The patient sleeps almost all day. She does not complain much. There was no report of any seizures. She does not appear to be
    confused. The patient states she was lying on the floor for about 1 hour,
    but she clearly denies any syncopal episode or any focal weakness. She
    just says she does not know why she was on the floor. She denies any
    fever(Constitutional), chills or cough. No abdominal pain, nausea, vomiting or diarrhea(GI).
    No blood in the stools. No pain with urination or any burning sensation
    with urination. No rash (skin).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 04-01-2010 at 03:59 PM.

  4. #4
    Default
    Thank you so much that def clears it up for me.

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