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help with HPI

  1. #1
    Default help with HPI
    Medical Coding Books
    What do you make of this HPI:

    "35-year old male, who says the last thing he remembers was being at a bus station, where he was visiting his family, when he was mugged by 2 people. Now he remembers walking up in the hospital. He says he never normally go the a hospital. He says this was not his destination. He denies any alcohol, but did say he smoked marijuana yesterday, and has taken Percocet for kidney stones, but other than that he was brought in via police, confused. He says he is having a bad headache. He denies any shortness of breath, nausea, vomiting and diarrhea. He says when he sits up he gets lightheaded, but that has since been resolved."

    ROS: Reviewed in the history and physical, otherwise reviewed and are negative.

    I'm not getting a comprehensive history.
    Karen, CPC
    Physician Chart Auditor

  2. Default
    Quote Originally Posted by Gemini18 View Post
    What do you make of this HPI:

    "35-year old male, who says the last thing he remembers was being at a bus station, where he was visiting his family, when he was mugged by 2 people. Now he remembers walking up in the hospital. He says he never normally go the a hospital. He says this was not his destination. He denies any alcohol, but did say he smoked marijuana yesterday, and has taken Percocet for kidney stones, but other than that he was brought in via police, confused. He says he is having a bad headache. He denies any shortness of breath, nausea, vomiting and diarrhea. He says when he sits up he gets lightheaded, but that has since been resolved."

    ROS: Reviewed in the history and physical, otherwise reviewed and are negative.

    I'm not getting a comprehensive history.
    this is what i see...
    context: was mugged and does not remember events
    location: head for headache
    modifying factors: took percocet
    associated signs and symptoms: denies sob, n/v and diarrhea.

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default 4 elements
    Location = head (headache)
    Severity = "bad"
    Context = mugged
    Assoc Symptoms = confused, lightheaded

    Could almost give duration ... as I'm presuming police brought him in today, but physician should really specify the time line.

    F Tessa Bartels, CPC, CEMC

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