Tools for documenting HPI

[Rose Thomas]

I am trying to find examples and/or specific guidelines for time based documentation. Any help would be appreciated.

[FTessaBartels]

Doreen,
Maybe an example will help:

Patient fell off swing yesterday, and noted immediate sharp pain in left wrist. This morning wrist is noticeably swollen and bruised.
Here you have 4 elements of HPI -
Duration - yesterday
Quality - sharp
Location - left wrist
Assoc sign - swollen, bruised

OR ...

Patient with intermittent chest pain for past two days, described as "mild, more like tightness," worse with exercise such as going up stairs
This gives up 5 HPI elements (you only need 4 for highest level)
Timing - intermittent
Location - chest
Duration - two days
Quality - mild
Context - worse w/ exercise


Another thing you could do is take some of the actual HPIs your doc has documented and show how you get only 1 HPI element (for example).

Good luck!

F Tessa Bartels, CPC, CPC-E/M