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joanne71178

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Can information from the PE be used in the History?

I have an ORtho Hospital Inpatient MCR Consult where the doctor gives me only 3 points in the HPI; Location, Context and s/sx. However, the doctor states a modifying factor of 'pain with hip motion' in the PE. (Expanded HPI)

I was taught I could not use info from the PE in any other part of the note, but one of the other coders was taught the info could be shared within the note.

Thoughts or guideline rules/gray area?

Thanks in advance
 
Good morning,

It appears your physician was describing an assessment of rang of motion with notation of any pain which is part of the exam.

For the HPI you would see "Quality" what type of pain it is - description or characteristic - representing complaint: sharp pain, dull ache, crushing pain, burning, radiating.....and so on. For how serious the condition is - "Severity" - intensity or degree - on a scale of 0-10 how bad is the pain - how hard to endure, mild tense, not too bad.

The differences between "Subjective and Objective Data"

Subjective Data: history, CC, ROS is the critical first step in determining the etiology of a patient's problem. What the patient tells you. Example: Mrs. G is a 54-year-old
hairdresser who reports pressure over her left chest “like an elephant sitting there,” which goes into her left neck and arm.

Objective data: What you detect during the examination All physical examination findings.
Example: Mrs. G is an older, overweightwhite female, who is pleasant and cooperative. BP 160/80, HR 96 and regular, respiratory rate 24, afebrile.

Hope this helps.
Lynn Stuckert, LPN, CPC, CPMA
 
In the HPI the dictated:
"This is an 84 year old woman who is community ambulator who has past orthopedic history of bilateral osteoarthrisits, but had a mechanical fall sustaining a displaced right subcapital hip fracture. She denies any other associated injuries, specifically no head or neck trauma."

Here we have Location, s/sx and Context. 3 HPI = Expanded

PE under Extremities the doctor dictated: 'Her right lower extremity is shortened and externally rotated. She has pain with motion, tenderness over proximal femur."

Here the doctor dictates 'pain with motion'. Since this in in the PE not in the HPI would I be able to use this for HPI as a Modifying Factor'?

The doctors dictation is rather poor. I was taught I am not 'allowed' to pull any 'points' from one portion of the note to use in another portion of the note, but a co-worker was taught the opposite.

Which is correct?
 
In the HPI the dictated:
"This is an 84 year old woman who is community ambulator who has past orthopedic history of bilateral osteoarthrisits, but had a mechanical fall sustaining a displaced right subcapital hip fracture. She denies any other associated injuries, specifically no head or neck trauma."

Here we have Location, s/sx and Context. 3 HPI = Expanded

PE under Extremities the doctor dictated: 'Her right lower extremity is shortened and externally rotated. She has pain with motion, tenderness over proximal femur."

Here the doctor dictates 'pain with motion'. Since this in in the PE not in the HPI would I be able to use this for HPI as a Modifying Factor'?

The doctors dictation is rather poor. I was taught I am not 'allowed' to pull any 'points' from one portion of the note to use in another portion of the note, but a co-worker was taught the opposite.

Which is considered correct?
 
You can take info from one part of the note because doctors don't always dictate exactly how we think they should. That being said, in this scenatio the doctor got the pain reaction when he examined the patient (objective portion of exam), not when the patient was giving the history (subjective). For example, if the patient had said "it hurts when I move it" you could have used this. But definitely not if the doctor noticed it during his exam.

This is what I was taught (which seems to be the same as you).
 
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