I am struggling with picking out HPI elements when the provider doesn't just "spell it out" for me.. I don't know why I am having such a hard time and unfortunately the compliance/auditor that I work with isn't very helpful. Can you please tell me which HPI elements that you see in this blurb:
History of Present Illness
Cardiology:
Notes: . The patient is here for yearly followup for her polyvalvular heart disease as noted below. The patient thinks that she doing well and really does not have any particular complaints. She has a manual exercise treadmill that she still uses and alternates that with a stationary bike. She says she tries to exercise 3 or 4 days a week, sometimes more, sometimes less. She and her husband continue to do all of the yard work and household chores and she doesn't really think that that is a struggle. She only admits that it takes him longer to do the things they do but they still get done. She denies any issues with dyspnea with exertion, she can climb stairs, carrying groceries and things of that nature without having to stop to rest. She doesn't recognize any great change in her tolerance for the things that she has to do around the house and/or the exercise.
She said she took her blood pressure couple times today and it was pretty bearable, once it was high side and again a recheck was on the low side. When I checked her blood pressure myself shows 160/90 and she says that it is highly unusual but she does admit that she has been "cheating a little bit" and in particular sodium intake may be higher lately. She is going to pay more attention to that. Last available laboratories that were done and are from 4/11/17 and was just a basic metabolic panel.
To me it reads like the patients medical history and not necessarily the reason the patient is there for a visit.
Any help would be greatly appreciated!
Jenn
History of Present Illness
Cardiology:
Notes: . The patient is here for yearly followup for her polyvalvular heart disease as noted below. The patient thinks that she doing well and really does not have any particular complaints. She has a manual exercise treadmill that she still uses and alternates that with a stationary bike. She says she tries to exercise 3 or 4 days a week, sometimes more, sometimes less. She and her husband continue to do all of the yard work and household chores and she doesn't really think that that is a struggle. She only admits that it takes him longer to do the things they do but they still get done. She denies any issues with dyspnea with exertion, she can climb stairs, carrying groceries and things of that nature without having to stop to rest. She doesn't recognize any great change in her tolerance for the things that she has to do around the house and/or the exercise.
She said she took her blood pressure couple times today and it was pretty bearable, once it was high side and again a recheck was on the low side. When I checked her blood pressure myself shows 160/90 and she says that it is highly unusual but she does admit that she has been "cheating a little bit" and in particular sodium intake may be higher lately. She is going to pay more attention to that. Last available laboratories that were done and are from 4/11/17 and was just a basic metabolic panel.
To me it reads like the patients medical history and not necessarily the reason the patient is there for a visit.
Any help would be greatly appreciated!
Jenn
