The HPI elements don't work well with chronic conditions, since they usually don't have a lot of descriptive characteristics. I only see one, here.
The rest of the note ("At present patient complains of no chest pain, no hypoglycemia, no nausea, no numbness, no polydipsia, no polyphasia, no polyuria, no vision problems and no vomiting."), I'd count as ROS: Cardiovascular, endocrine, digestive, nervous, urinary & ENMT. Overall, I'd say that you've got an expanded probelm focused history there. Hope that helps!
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join