Originally Posted by SHobbs
I am pretty new to auditing charts and need some expertise on the auditing of a chart HPI. The HPI states:
Patient is here in the office for review of labs. Endocrine: Patient is here for follow up of diabetes. Goal for this visit is : Establish care in diabetes. She has type 2 diabetes. 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.
How am I supposed to determine the HPI elements from this? Can I count the signs/symptoms as 1 qualifier?
I'd score this as brief; you have 1 chronic condition reviewed *IF the treatment plan has been documented in the MDM - chronic conditions need to have the condition, current treatment plan, future treatment plan, and any updates on symptoms that pertain to the condition, documented somewhere in the note, to count for HPI.
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!