Wiki E/M hpi/ Modifying factors question....

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jettagirlfl

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In the HPI for a consult, my question is: when the Dr is stating the kind of surgery the pt just had or what they recently went though in surgery, can I use this as a modifying factor to count as 1 of my hpi elemtns?
I know if they pt has taken tylenol or put ice on their leg,or whatever the patient has tried to do to relieve their pain, that considers modifying factors. Thanks!!!
 
It depends

It depends on whether the surgery was for treatment of the chief complaint for THIS visit.

For example if the patient comes in with a sprained ankle and as part of the history you note that the patient had an appendectomy performed 2 weeks ago that would NOT be a modifying factor to the newly sprained ankle.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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