Wiki Do the elements need to directly relate to the current complaint?

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jenpudua32

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I have a question regarding the HPI. Do the elements need to directly relate to the current complaint? For example our doctor is being consulted for abdominal pain. But the HPI also mentions severe headaches. Would we be able to count 1 point for location:abdomen. 1 pt for associated s/s: headaches. 1 pt for severity: severe. I question whether a headache can even be considered as an associated sign since it may or may be a separate issue from the abdominal pain altogether. Also severe relates to the headache not the abdominal pain, which is the current complaint.... what's your opinion. Thanks in advance!
 
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hi, I am new to coding. My opinion is :1.Abdomen is location plus 1. for sign and symptoms -headache=2 elements for HPI If patient comes for abdominal pain. But if patient comes for headache, then you will have location, severity and associated signs and symptoms -abdominal pain =3 elements. I would not mix them but focus on the Main reason for the visit. In this case it’s abdominal pain so I would focus on HPI elements only for abdominal pain.
 
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natashalage said:
hi, I am new to coding. My opinion is :1.Abdomen is location plus 1. for sign and symptoms -headache=2 elements for HPI If patient comes for abdominal pain. But if patient comes for headache, then you will have location, severity and associated signs and symptoms -abdominal pain =3 elements. I would not mix them but focus on the Main reason for the visit. In this case it’s abdominal pain so I would focus on HPI elements only for abdominal pain.
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Thank you :)
 
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