ED Coding and Reimbursement Alert

Question: Can I get an opinion on chief complaint and number of elements in this HPI?

Per EMS, patient's family called 911 because he/she has not been eating or drinking for the last week, worried that the patient may be dehydrated and took Maalox at the suggestion of the concerned family member without any changes. Patient with known metastatic breast cancer having chosen to avoid aggressive treatment of same. Patient states he/she is in no pain, no nausea, thinks that he/she has been eating and drinking enough and not sure why family called 911.

Answer: This is tricky since the patient does not seem to have a complaint. The family fears dehydration, which is the closest thing we have to a chief complaint. See the HPI elements as added in bold and brackets below:

Per EMS, patient's family called 911 because he/she has not been eating or drinking for the last week [Duration], worried that the patient may be dehydrated and took Maalox at the suggestion of the concerned family member without any changes. [Context]. Patient with known metastatic breast no pain, no nausea, [Associated Signs and Symptoms] thinks that she has been eating and drinking enough and not sure why family called 911.