I am having difficulty on the HPI elements of this note. The more I look at it the more I second guess myself. Any help on the HPI elements would be greatly appreciated!!
Here is the HPI:
The patient presents for a sleep evaluation. The referring provider is XXXX. ( The patient is here to review a recent diagnostic polysomnogram.) The sleep problem has been occurring in a persistent pattern. Daytime symptoms include daytime sleepiness, decreased energy, fatigue and hypertension. The patient reports snoring and snoring every night. The patient reports mouth breathing during sleep but denies awakening with shortness of breath or awakening with choking feeling. and goes to bet at 12am. On days off the patient wakes up at 6am and goes to bed at 10pm. Usually falls asleep within 3 hours. patient feels that 8 hours of sleep is needed per night. Patient awakes 1 time at night and is awake for The patient wakes up for use of bathroom. During the first few minutes after awakening the patient feels very groggy after waking up.
I know I can get Timing and Associated signs/symptoms. Could you use the fact that the patient is here to review a recent diagnostic polysomnogram as Context? Could the fact that the patient feels that 8 hours of sleep is needed per night be used as a Modifying Factor?? Would this be considered Quality, "During the first few minutes after awakening the patient feels very groggy after waking up"??
Here is the HPI:
The patient presents for a sleep evaluation. The referring provider is XXXX. ( The patient is here to review a recent diagnostic polysomnogram.) The sleep problem has been occurring in a persistent pattern. Daytime symptoms include daytime sleepiness, decreased energy, fatigue and hypertension. The patient reports snoring and snoring every night. The patient reports mouth breathing during sleep but denies awakening with shortness of breath or awakening with choking feeling. and goes to bet at 12am. On days off the patient wakes up at 6am and goes to bed at 10pm. Usually falls asleep within 3 hours. patient feels that 8 hours of sleep is needed per night. Patient awakes 1 time at night and is awake for The patient wakes up for use of bathroom. During the first few minutes after awakening the patient feels very groggy after waking up.
I know I can get Timing and Associated signs/symptoms. Could you use the fact that the patient is here to review a recent diagnostic polysomnogram as Context? Could the fact that the patient feels that 8 hours of sleep is needed per night be used as a Modifying Factor?? Would this be considered Quality, "During the first few minutes after awakening the patient feels very groggy after waking up"??