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HPI- Severity

  1. Default HPI- Severity
    Medical Coding Books
    Hello, I am fairly new to coding and have a question on the SEVERITY element of the HPI. If the physician stes in HPI that patient is feeling "better" could/should this be considered severity?
    Many Thanks!

  2. #2
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    Albuquerque, NM
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    Severity=discomfort sensation or pain; self-assessment on scal of 1-10 comparison to previously experienced pain; ability of paitent ot continue to function; was the patient awakened. Documentation example: History of intermittent, sharp pain in left lower back that has become more intense, interrupting patieint's sleep.

    I would consider patient is feeling better to fall under Quality.

  3. #3
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    Quote Originally Posted by malinusky View Post
    Hello, I am fairly new to coding and have a question on the SEVERITY element of the HPI. If the physician stes in HPI that patient is feeling "better" could/should this be considered severity?
    Many Thanks!
    I'd say no - some people might interpret it that way, though, so it's going to be up to you. I'd look at it as: why are they better? Is this a follow up visit, where she's already tried a treatment? If so, it may fit under modifying factors, but I'd have to see it in context to tell you for sure. Modifying factors tells you what the patient has done to either improve their problem, or make it worse.

    Severity is pertinent to the problem itself - (Like a pain scale rating, for example). It should be relatively specific, to give you an idea of how extreme (or not) the symptoms are or have been. (eg, mild anxiety, extremely nauseous, highly irritable)

    Hope that helps!

  4. #4
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    Quote Originally Posted by penny48 View Post
    Severity=discomfort sensation or pain; self-assessment on scal of 1-10 comparison to previously experienced pain; ability of paitent ot continue to function; was the patient awakened. Documentation example: History of intermittent, sharp pain in left lower back that has become more intense, interrupting patieint's sleep.

    I would consider patient is feeling better to fall under Quality.
    I wouldn't put it under quality at all - quality, like severity, describes the characteristics of the problem itself; not the overall well-being of the patient. Quality examples are:
    productive cough
    aching back pain
    stabbing pain
    itching, scaly lesion

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