Patient presents with mixed hyperlipidemia. You have a chief complaint.
Originally Posted by pglazener
Most recent lab tests include total cholesterol level ( 179 mg/dl ), triglycerides ( 265 mg/dl ), HDL ( 37 mg/dL ), LDL cholesterol ( 85 mg/dl ), small ldl 1553, hdl-p 27.9, and ldl-p 2350. Although documented in the subjective portion of the note, I'd reserve this information for your MDM/data. These are lab results. You might be able to get "timing" out of "most recent".
had pap and they obtained labs, was told to see pcp for possible meds. Good information...not clear if it's related to the chief complaint, though. If I was feeling generous, I might credit the 'obtained labs' as modifying factors, but you'd have to catch me on a really good day.
Overall, this is a brief History, I don't see any system review, or PFSH, so couldn't comment on whether or not you would be able to do better than just the single HPI element.
Show your physician the eight history elements, and explain to him that he needs to be able to tell you the story of this patient's condition and associated co-morbidities or unrelated problems. This is a new patient.....is there more that's going on? Sometimes it's helpful to find out what they typically ask the patient, and then help them translate that into a concise note. I tell my providers...."your documentation has to explain to me what went on in the exam room, I can't be inside your head"!!
Pam Brooks, MHA, CPC, PCS, COC
Dover, NH 03820
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