Wiki A list of goals for the HPI?

[sharonvalwa]

Hi,
CC - F/U

HPI : The documentation in the HPI is a copy of the "AHA/ACCF Secondary Prevention/Risk reduction 2011 guidelines for CAD", and the HPI section lists the goals from the guidelines, such as : LDL goal <100 mg/dl or < 70 mg/dl if acute coronary event, BP goal <140/90 or <130/80 with diabetes or CKD, Nutrition: alcohol intake <26g/day and saturated fats <7% of calories, ACE inhibitor indefinitely if no contraindication, Influenza vaccine yearly, Physical activity 30 minutes 5-7d weekly, BMI goal 18.5-24.9 and waist circumference : <40' males; 36" females, ect. ect. ect .

ROS: pt. had episode of panic attack on a cruise ship, thought he was having MI, currently asymptomatic.

PMH: HTN, dislocated finger

SH: [Tobacco: Never Smoker]

So, as you can see, the statement for the HPI seems to be a reference to the AHA/ACCF guidelines for CAD and gives no real information on this particular patient and whether or not the patient is meeting or actively pursing these goals .... I don't think any of this counts for any element of E/M? I think the statement in the ROS will be used for the HPI and that is all I can do for this note. Anyone else ever see a list of recommended guidelines used as a part of the E/M note? Thanks

 

[Pathos]

In short, yes you cannot use guidelines or instructional text as the HPI, since that would not be a personal description of the patient history of illness. That would not qualify for a preventative visit either.

Also, an E/M should have a Chief Complaint that describes the medical reason for the visit and briefly explain what the patient is going through. I doubt "FU" would qualify for that.

CMS E/M guidelines say about both:

"CHIEF COMPLAINT (CC)
The CC is a concise statement describing the symptom, problem, condition,
diagnosis, physician recommended return, or other factor that is the reason for
the encounter, usually stated in the patient’s own words.
DG: The medical record should clearly reflect the chief complaint."


"History of Present Illness (HPI)
HPI is a chronological description of the development of the patient’s present illness
from the first sign and/or symptom or from the previous encounter to the present. HPI
elements are:"


ROS could be used in place of the HPI, just not sure what else you could use for the actual ROS, since you can't count one element twice (both in the HPI and ROS).

PMH and SH seem fine also.


Hope that helps!