Wiki HELP!! HPI Audit-Inpatient admit

[MidwestCoder]

This is the HPI section of an H&P for hospital admit.

73 yow female with 2 day history of fever and some respiratory problems. She was found be her son this evening chilling and incontinent of urine. She was disoriented and unable to talk when found. Denies CP but was SOB. Has chronic afib and diabetes.

Any suggestions?

Thank you!

 

[FTessaBartels]

4 HPI elements

Duration: 2 day history
Location: respiratory
Context: found by son
Assoc Signs: chilling, incontinent of urine, disoriented

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[MidwestCoder]

Thank you!