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Lab results only listed as HPI??

  1. Question Lab results only listed as HPI??
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    Can lab results only (no other documentation) count toward brief HPI? I don't think it counts-thoughts?

    HPI listed as the following:
    64yo PSA 6/9 4.1 PSA 5/8 3.3

    Thanks in advance for responding

  2. Default
    What's the Chief Complaint? If CC is "f/up abnormal PSA lab" the results could be counted as severity as how bad/better the PSA levels are

  3. Default
    The DOS is 12/15/09

    CC is listed as: "6 mos f/u " and then "f/u PSA".

    I thought of severity but the MD did not state abnormal, just PSA f/u. Thanks again for responding!

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