Wiki Elements

[NESmith]

Could someone tell me what elements you see in this HPI. We are having alittle disagreement and I need help.
HPI: Rreview of labs in detail with the patient. Cholesterol is clearly elevated, blood sugar mildly elevated. Thyroid levels are stable.
Due for GYN yearly physical. Has not scheduled yet.
Allergic rhinitis is stable however worse during spring and fall.
Thanks for the help.

 

[FTessaBartels]

What is encounter for?

What kind of encounter is this? This doesn't conform to any type of HPI that I've previously seen. This almost seems to be a preventie visit ... which doesn't need a formal HPI in any case.

The HPI is supposed to be what the PATIENT says about the problem that brings him/her to the doctor for this visit. I might listen to an argument for "status of three chronic problems."

Hope that helps.

F Tessa Bartels, CPC, CEMC