# Lab results only listed as HPI??



## acjarvis (Aug 27, 2010)

Can lab results only (no other documentation) count toward brief HPI? I don't think it counts-thoughts?

HPI listed as the following:
64yo  PSA 6/9 4.1  PSA 5/8 3.3

Thanks in advance for responding


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## sbicknell (Aug 27, 2010)

What's the Chief Complaint?  If CC is "f/up abnormal PSA lab" the results could be counted as severity as how bad/better the PSA levels are


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## acjarvis (Aug 30, 2010)

The DOS is 12/15/09 

CC is listed as: "6 mos f/u "  and then  "f/u PSA".  

I thought of severity but the MD did not state abnormal, just PSA f/u. Thanks again for responding!


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