# E/M hpi/ Modifying factors question....



## jettagirlfl (Oct 13, 2010)

In the HPI for a consult, my question is:  when the Dr is stating the kind of surgery the pt just had or what they recently went though in surgery, can I use this as a modifying factor to count as 1 of my hpi elemtns?
I know if they pt has taken tylenol or put ice on their leg,or whatever the patient has tried to do to relieve their pain, that considers modifying factors.   Thanks!!!


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## FTessaBartels (Oct 19, 2010)

*It depends*

It depends on whether the surgery was for treatment of the chief complaint for THIS visit.

For example if the patient comes in with a sprained ankle and as part of the history you note that the patient had an appendectomy performed 2 weeks ago that would NOT be a modifying factor to the newly sprained ankle. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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