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HPI -Sore throat

  1. #1
    Default HPI -Sore throat
    Medical Coding Books

    Someone help you if the HPI states - "Patient has sore throat for 2days" - Can we take Throat in Location and Sore in Quality.

    Thank you all in advance,

    Purnima S, CPC

  2. #2
    Default Hpi

    I think " Yes we can take as quality".

    Sore throat = Sorness in the throat, or inflamation in the throat.

    So soreness can be taken as quality.


  3. #3
    Default Throat as Location
    We are asking the same thing in our office. We agree that sore can be used as quality, but we are divided on throat as a location. Can you use throat as the location?

    For an additional example, could you use Kidney as location and Pain for quality if a patient states they have kidney pain?

  4. #4
    Austin, Texas
    The throat is the anterior part of the neck, in front of the vertebral column. It consists of the pharynx and larynx. Location of the throat is a particular place or part of the body that does not really need further definition. Stomach/abdominal pain, on the other hand, is a broad term for location that can be further defined into quadrants...same with "back pain" which would require further definition.

  5. #5
    Austin, Texas
    A partial list of the dimensions of pain includes pain behavior (e.g., grimacing, limping), pain intensity (the magnitude of experienced pain), pain affect (e.g., unpleasantness of experienced pain), pain beliefs (e.g., sense of control over pain, beliefs about the meaning of pain), and quality of life (physical and social functioning). For kidney pain, is it a sharp shooting type pain, mild pain, excruciating pain, occasional pain, dull ache type pain? Use a VAS pain scale to measure differences from day to day or visit to visit.

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