Wiki Exam documentation in the HPI

[Belarm3]

Hi everyone,
One of my providers listed the patient's vitals in the HPI. I was wondering if anyone knows of any documentation that states you can or cannot count information in the HPI (such as the vitals in this case) for the examination portion of the note? Appreciate any help.
Thank you!

 

[thomas7331]

There is no guideline that says HPI or exam have to be documented in a particular part of a note. As an objective finding, vital signs are part of the exam and should be counted as such and not as part of the HPI which is account of the problem prior to the encounter.

 

[Belarm3]

There is no guideline that says HPI or exam have to be documented in a particular part of a note. As an objective finding, vital signs are part of the exam and should be counted as such and not as part of the HPI which is account of the problem prior to the encounter.

Thank you so much for responding. I truly appreciate it.

 

[Pathos]

While structuring the patient note into three separate sections (History, Exam, MDM) is often useful, I agree with Thomas. I have yet to see any specific requirements which isolates the History, Examination and Medical Decision Making into specific slots/areas of the medical note. I have audited providers who write everything in free text (or dictation), and the whole note is one big paragraph. If the elements are there, I can still count them as appropriate (without double dipping) even without having the three E/M components split up.

 

[Belarm3]

While structuring the patient note into three separate sections (History, Exam, MDM) is often useful, I agree with Thomas. I have yet to see any specific requirements which isolates the History, Examination and Medical Decision Making into specific slots/areas of the medical note. I have audited providers who write everything in free text (or dictation), and the whole note is one big paragraph. If the elements are there, I can still count them as appropriate (without double dipping) even without having the three E/M components split up.

Thank you so much. Appreciate the input.