# How many elements do you count



## todd5400 (Jan 20, 2009)

I would like opinions regarding History bullets you count

78 yr old who fell at home.  She was getting out of bed to go to bathroom with a syndopal episode.  She fell hitting the face.  She complains of pain between the shoulders and face.  She sustained a rib laceration and nasal abrasion.  She is amnestic to the fall.

Thanks in advance
Mary


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## Love Coding! (Jan 20, 2009)

Is this just for history (past, family, social)? Or do you mean History of Present Illness?

Thanks,

dscoder74


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## Love Coding! (Jan 20, 2009)

I see context (for the fall)..

Location (shoulders)

Quality (pain, could you severity if it showed severity of the pain)

Associated Signs and Symptoms (laceration)

Any other opinions?

dscoder74


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## ringalls (Jan 20, 2009)

I see...
context (feel getting out bed)

Location  (shoulder)

Associated Signs and Symptoms (laceration)

I would not use pain as quality usually   to use quality it would be (sharp/dull/throbbing ect) 

So I believe there are 3 elements in this HPI
Robin Ingalls-Fitzgerald cpc,cemc,ccs,fcs


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## FTessaBartels (Jan 20, 2009)

*Hpi*

I'm *assuming* that you have a separate chief complaint ...  and that this is just HPI.

I see:
Context - getting out of bed w/ syncopal episode
Assoc signs - pain, amnesiac to fall
Quality - laceration & abrasion
Location - shoulder, face, rib, nose

Too bad the doctor didn't tell us WHEN she fell ... you'd have duration.

F Tessa Bartels, CPC, CEMC


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## Inquisitor (Jan 21, 2009)

What if there is no separate CC?  Would you infer from the HPI that the CC was a head, shoulder, face problem and then count all the HPI elements within the statement?

Just wondering...


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