Wiki help with elements

[ggparker14]

Can I get opinions on number of elements in this HPI?

Chief complaint: shortness of breath

HPI: Patient presenting with shortness of breath since 6 pm last night. Patient was recently relesed after hip sugery and was having difficulty breathing over the weekend. She has some coughing and tonight started to have some wheezing and audible breathing. Patient has no chest pain, abdominal pain, nausea, voming, weakness, numbness, tingling. She has never had anything like this before.

thank you for any help.

 

[nyyankees]

Can I get opinions on number of elements in this HPI?

Chief complaint: shortness of breath

HPI: Patient presenting with shortness of breath since 6 pm last night. Patient was recently relesed after hip sugery and was having difficulty breathing over the weekend. She has some coughing and tonight started to have some wheezing and audible breathing. Patient has no chest pain, abdominal pain, nausea, voming, weakness, numbness, tingling. She has never had anything like this before.

thank you for any help.

Location = lungs
duration = last night
signs & symptoms = coughing
quality = audible

anyone else?

 

[a.montaruli@gmail.com]

Ill be honest I only see three. Although it is obvious that shortness of breath and wheezing would be the lungs, it does not say anywhere in the record that it actually is the lungs. Coders are not allowed to assume. So therefore we have:

Duration: Last Night
Associated S&S: Coughing
Quality: Audible

The rest of the record can be counted as the ROS

Andrew Montaruli

 

[Monika Liddle]

I agree with Andrew - I have been taught you can not use shortness of breath for location because you can not assume the location of lungs.

Duration: last night
Associated S&S: coughing
Quality: audible

 

[LLovett]

There are at least 4

Modifying factor would be the surgery that caused difficulty breathing. It could also be argued that duration was this weekend and timing was 6pm last night.

Just my take on it,

Laura, CPC, CPMA, CEMC

 

[ollielooya]

Would this qualify for context? " Patient was recently relesed after hip surgery and was having difficulty breathing over the weekend". You're looking for the magic four elements, right?