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HPI elements - wants to know

  1. #1
    Default HPI elements - wants to know
    Medical Coding Books
    Please check with these HPI elements

    Fever started on monday, got worse at 8 pm today. wants to know if "8pm" timing

    deformity to knee, TV fell on leg, non -ambulatory. wants to know if "non -ambulatory" severity

    knee pain , fell y day, unable to bear weight, wants to know if "unable to bear weight " severity

    Fever started on monday,102 degree, got worse at 8 pm today. wants to know if "102" severity

  2. #2
    Location
    Swainsboro/Statesboro
    Posts
    671
    Default
    Severity defination : level of pain (pain scale, temps to 102, extremely agitated.

    So for your examples below the I think the last 2 would fall under severity and the timing one is correct.

    My opinion for the non-ambulatory would be quality.

    Thanks, Sue
    Susan Edwards, CPC, CEDC
    smecoder@gmail.com

  3. #3
    Default
    Quote Originally Posted by preema View Post
    Please check with these HPI elements

    Fever started on monday, got worse at 8 pm today. wants to know if "8pm" timing

    deformity to knee, TV fell on leg, non -ambulatory. wants to know if "non -ambulatory" severity

    knee pain , fell y day, unable to bear weight, wants to know if "unable to bear weight " severity

    Fever started on monday,102 degree, got worse at 8 pm today. wants to know if "102" severity
    8pm today would count as timing - timing is when, or how often something occurs.
    I agree with non-ambulatory being Quality, and the others being severity, but I think that a better fit would be "tv fell on leg" = Context.

    Quality = How you'd describe the problem
    Location = Where the problem occurs
    Severity = How bad it is
    Timing = When/How often it occurs
    Duration = The total length of time that the problem has been occuring
    Context = Circumstances surrounding the problem
    Modifying Factors = Actions taken to try to affect the problem
    Associated Signs Symptoms = Related symptoms, which are probably the result of the same condition as the main problem.


  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Timing vs Duration
    Duration refers to how long the problem has been occurring.
    Timing refers to cyclical nature ... intermittent, constant

    Fever started on monday, got worse at 8 pm today - Duration and severity (got worse)

    deformity to knee, TV fell on leg, non -ambulatory
    - Location, context, associated sign/symptom (maybe ... can't tell if the patient was already non-ambulatory or if this is a result of the injury)

    knee pain , fell y day, unable to bear weight, - Location, duration, severity OR associated sign/symptom (but not both)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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