# HPI Elements-What HPI elements



## klthompson (Jul 16, 2012)

What HPI elements can be found in the following chart note?

"History of Present Illness 
:  
       pt sent here to discuss surgical removal of endoscopically unresectable hepatic flexure polyp. This was just a screening colonoscopy. He has had minimal left abd. pain since colonscopy. No blood in stool. Patholgy results reviewed with pt and his wife at this time. "

Thanks for your thoughts and help.


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## MnTwins29 (Jul 16, 2012)

*At first glance...*

I see three:  Location (left abdomen), Quality (minimal), and duration (...since colonoscopy, as long as the date of this is documented somewhere).


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## klthompson (Jul 16, 2012)

the date of the colonoscopy is listed in the Chief Complaint of the note, but the nurse documents the CC, can I still use it?  Also can the colon polyps listed in the HPI be used for anything?


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## FTessaBartels (Jul 16, 2012)

*No blood in stool*

You also have *associated sign/symptom* with "no blood in stool."

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## CC5657 (Jul 16, 2012)

*Just wondering??*

Could you use context for "since colonoscopy"??


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## Naveen Rachagolla (Sep 12, 2012)

CC5657 said:


> Could you use context for "since colonoscopy"??



can someone give answer for this, because my openion is we consider this as context and i just want to confirm it.


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## abhishekrane32@yahoo.com (Sep 15, 2012)

there are only 4 HPI in the text

left abdomen - location

minimal pain - severity/quality

since colonoscopy - can be considered as context and not the duration

 no blood in stool - associated sign and symptom


abhishek


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## valleycoder (Sep 16, 2012)

I agree with 4 hpi's. 

Location, duration (..since colonoscopy), severity or quality (minimal pain), assoc signs (no blood in stool).

This is an ideal visit to bill based on time instead of elements, if time was documented.


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