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help with elements

  1. #1
    Default help with elements
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    Please give me other opinions on number of elements in this HPI.

    Patient seen here early today with c/o insomnia and medications not working, arrives via law enforcement on ECO. Patient apparently left ED and went to sheriff's office stating she had no place to go and how could she get in jail. She reportedly then walked out into the street.

    Thanks for any help.

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by rhblevins61@yahoo.com View Post
    Please give me other opinions on number of elements in this HPI.

    Patient seen here early today with c/o insomnia and medications not working, arrives via law enforcement on ECO. Patient apparently left ED and went to sheriff's office stating she had no place to go and how could she get in jail. She reportedly then walked out into the street.

    Thanks for any help.
    At best I think there are 3 elements; meds not working=Modifying factor, arrives via law enforcement on ECO=Context, walked out into the street=Associated signs/symptoms.

    Other opinions?
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #3
    Default
    thanks for your help

  4. #4
    Location
    Ellenville, New York
    Posts
    1,176
    Default I see two...
    Only for the meds not working and going to the sherrif office (modifying factors and context). Not sure about walking in the street being a S/S being a symptom, mainly because of the other information about wanting to go to jail. But then, maybe I am just being too conservative...

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default 3 hpi
    Duration - "early today"
    Modifying factors - "meds not working"
    Context - "arrives via law enforcement ... "

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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