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Tools for documenting HPI

  1. #1
    Location
    Hartford, CT
    Posts
    723
    Default Tools for documenting HPI
    Exam Training Packages
    Hi everyone,
    My docs are looking for some type of tool they can use to help them remember what they need to document for HPI. We have medicare's E/M Documentation Auditors' Instructions, but this doesn't really help them. I figured rather than reinventing the wheel I'd see if anyone has something they use. Thanks.

    Doreen, CPC

  2. #2
    Location
    North Carolina
    Posts
    3,126

  3. #3
    Location
    North Carolina
    Posts
    3,126
    Default
    It just occured to me that you were probably looking for an actual form...oops. You might be able to critique this one.

    http://arlingtonchiropractic.net/ima...nt%20Forms.pdf

    I have one more area I can check. I'll see what I can dig up...that's if someone else doesn't provide something sooner.

  4. #4
    Location
    Hartford, CT
    Posts
    723
    Default
    Thanks, at least I have someplace to start. I don't know why they have such a problem with the HPI, but this seems to be their weakest area of documentation.

    Doreen

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default Hpi
    History of Present Illness has 8 elements, as follows:

    Location - "where" - site, diffuse or localized
    Quality - "what kind" - sharp, dull, constant, intermittent, improved, worse
    Severity - "how bad is it" - pain scale 1-10, mild or severe
    Duration - "how long" - length of time it has been present
    Timing - "Is there a pattern" - relation ot something else, continuous or repetitive
    Context - "what brings it on" - does it occur with a specific activity?
    Modifying factors - "what makes it better or worse" - prior treatments or medications tried, worse w/ exercise, better with heat
    Assoc Signs & Symptoms - "what comes with it" - symptoms that accompany the main symptom.

    F Tessa Bartels, CPC, CPC-E/M

  6. #6
    Location
    north seattle wa
    Posts
    103
    Default History check sheet
    I PM'd you.

  7. #7
    Location
    Hartford, CT
    Posts
    723
    Default
    Thansk, Wendy, I replied to your message. As for the 8 elements, I have explained in every way I can think of what needs to be document. The doc I work for seem to do better with visual aids.

    Doreen, CPC

  8. #8
    Location
    north seattle wa
    Posts
    103
    Default check list
    Doreen,

    I sent couple to your other email. Hope they work.

  9. #9
    Default
    http://www.aafp.org/fpm/20031000/51twot.html

    here's another ... it has the other components too ...

  10. #10
    Location
    Hartford, CT
    Posts
    723
    Default
    Thanks to everyone for your help.

    Doreen

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