# Documentation in HPI



## Nkeith (Apr 16, 2015)

I have a chart that in the HPI states " He has a history of DM, HTN, High Cholesterol, CKD, and alpha 1 antitrypsin deficiency/NASH Cirrhosis.  He is S/p Liver transplant in 2007.  he was seen by Dr.X on "Date" for s/p liver transplant check up . patient was well and lost a great deal of weight.  He has however developed some renal insufficiency.  Decreased Prograf to 1mg and planned to check liver enzymes for stability,  He had DM foot exam an "Date" with debridement.   Labs reviewed mention "BS 200, creat 1.5 with GFR 51, liver function normal" Assessment :' 1. Diabetes 250.00 ( Primary),2. Benign Essential Hypertension- 401.1, 3.Hyperlipidemia 272.4, 4. History of liver transplant V42.7, 5. Borderline Glaucoma (glaucoma Suspect) 365.00, 6. age related nuclear cataract of both eyes, 7. Routine general medical exam V70.0" Treatment is listed for Diabetes,HTN,Hyperlipidemia, History of transplant and under that notes : " Notes: follow up with Dr. X who saw him on "Date"Dr.X decreased Prograf as kidney function had been worsening with Cr at 1.8 . At last control on Date" ( week prior to this visit)" Cr went does to 1.5 with GFR 51." Treatment for Glaucoma, cataract and exam are all noted.  QUESTION  is there enough here to support the alpha 1 antitrypsin deficiency diagnosis and the SKD mentioned in HPI? Since the Dr stated "History of" in HPI its causing some questions.  Would those pass if in a RADV audit?  Sorry so long!


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## emcee101 (Apr 22, 2015)

I would think that you are safe in a RADV. AAt is produced in the liver and there is plenty of documentation to follow MEAT/TAMPER guidelines since they state that he has had a transplant and the liver enzymes will be checked. I would submit this without question.


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