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help with elements

  1. #1
    Default help with elements
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    Can I get others opinions on chief complaint and number of elements in this HPI?

    Per EMS, patient's family called 911 because he/she has not been eating or drinking for the last week, worried that the patient may be dehydrated. Patient with known metastic breast cancer having chosen to avoid aggressive treatment of same. Patient states he/she is in no pain, no nausea, thinks that he/she has been eating and drinking enough and not sure why family called 911.

    Thanks for any help.

  2. #2
    Default help with elements
    It is really hard to establish some elements because it sounds like a past history but, maybe you could count one element as constitutional (no eating or drinking) and the other duration(last week). Don't know if this will help???

  3. #3
    Location
    Swainsboro/Statesboro
    Posts
    673
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    You can use the nausea as associated signs/symptoms. You could use the information about the breast cancer as modifying factors.
    Susan Edwards, CPC, CEDC, AAPC Fellow
    Swainsboro/Statesboro Georgia President

    smecoder@gmail.com

  4. Default
    you have 4 elements in your HPI: Context, Duration, Associated Signs and Symptoms, and Modifying Factors. Your CC is: "not eating or drinking"

    Context: worried pt may be dehydrated

    Duration: for the last week

    Asst S&S: no pain no nausea

    Modifying: metastic breast cancer

  5. #5
    Location
    Virginia Beach Local Chapter
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    997
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    I agree you have 4 elements. It is so nice to see so many people on the forum willing to help each other.
    Judy Wilson, CPC,COC,CPCO,CPPM,CPB,CPC-P,CPC-I,CANPC,AAPC FELLOW,CMRS

    Past AAPC-CA BOD 2010 - 2013 & 2015 - 2017


    judy@anes.hrcoxmail.com

    Nothing is impossible, the word itself says ‘I’m possible’!
    -Audrey Hepburn

  6. #6
    Location
    Virginia Beach Local Chapter
    Posts
    997
    Default
    I agree you have 4 elements. It is so nice to see so many people on the forum willing to help each other.
    Judy Wilson, CPC,COC,CPCO,CPPM,CPB,CPC-P,CPC-I,CANPC,AAPC FELLOW,CMRS

    Past AAPC-CA BOD 2010 - 2013 & 2015 - 2017


    judy@anes.hrcoxmail.com

    Nothing is impossible, the word itself says ‘I’m possible’!
    -Audrey Hepburn

  7. #7
    Default
    Thanks so much for all the help.

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