# Tools for documenting HPI



## dclark7 (Oct 8, 2008)

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


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## RebeccaWoodward* (Oct 8, 2008)

Does this help?

http://emuniversity.com/HistoryofPresentIllness.html

http://www.som.tulane.edu/fpp/billing_new/Rework_Sep06/PDF files/Part 2 Doc a Hx.pdf


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## RebeccaWoodward* (Oct 8, 2008)

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/images/forms/New Patient Forms.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.


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## dclark7 (Oct 8, 2008)

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


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## FTessaBartels (Oct 8, 2008)

*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


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## Cottrell (Oct 8, 2008)

*History check sheet*

I PM'd you.


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## dclark7 (Oct 9, 2008)

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


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## Cottrell (Oct 9, 2008)

*check list*

Doreen,

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


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## ARCPC9491 (Oct 10, 2008)

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

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


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## dclark7 (Oct 10, 2008)

Thanks to everyone for your help.

Doreen


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## Rose Thomas (Oct 10, 2008)

*Time based coding*

I am trying to find examples and/or specific guidelines for time based documentation.  Any help would be appreciated.


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## FTessaBartels (Oct 10, 2008)

*Examples help*

Doreen,
Maybe an example will  help:

Patient fell off swing *yesterday*, and noted immediate *sharp* pain in *left wrist*. This morning wrist is noticeably *swollen and bruised*.
Here you have 4 elements of HPI -
Duration - yesterday
Quality - sharp
Location - left wrist
Assoc sign - swollen, bruised

*OR ... *

Patient with *intermittent** chest* pain for past *two days*, described as "*mild, *more like tightness," *worse with exercise *such as going up stairs
This gives up 5 HPI elements (you only need 4 for highest level)
Timing - intermittent
Location - chest
Duration - two days
Quality - mild
Context - worse w/ exercise


Another thing you could do is take some of the actual HPIs your doc has documented and show how you get only 1 HPI element (for example). 

Good luck!

F Tessa Bartels, CPC, CPC-E/M


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