Wiki determining the level of an HPI

[Colliemom]

Good morning,

I need a second or even a third opinion on this. I am auditing a note, and under the HPI the only documentation is as follows:

Chief complaint - This 65 year old female presents for hypertension.
History of Present Illness - "Hypertension - risk factors include age over 60 and obesity. Additional information: follow up"

What, if any, elements of the HPI would you credit for this documentation?

thanks!

 

[thomas7331]

This really isn't a HPI, but I would classify it as 'brief' under the argument that you could call it a status of one chronic condition, or going by elements using 'hyper' as quality and the 'risk factors' as modifying factors. Either way, it only barely meets the requirements for the lowest level of HPI in that it identifies the patient's problem and reason for being seen. Strict auditors might say it does not qualify as an HPI at all because there really isn't enough information documented to be able to tell the actual status of the condition, and there's no history of the problem leading up to the visit.

 

[skiboi]

Hpi

I would tend to agree with Thomas-
I might give them location but that is it and that's being very generous. I think this is a great opportunity for you to do some education to that provider and give him/her the tools to properly document a qualifying HPI. When I had providers struggle with certain areas I gave them copies of my own auditing sheet so they could use it as a reference when documenting. It worked fantastic and rarely had problems after that.
Jeffrey

 

[Colliemom]

thank you