Wiki Help with HPI - who has dialysis

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Gemini18

Gemini18

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I have an HPI that reads:

Pt is a 40-year old gentleman who has dialysis Tues, Thurs and Saturday and was out of town for the holidays and was driving back. Unfortunately he was not able to make it to dialysis session, so he missed Tuesday, also Wednesday and then came in on Thursday with shortness of breath to the Emergency Room.

How many elements do you get? I have 2: Quality (shortness of breath); Assoc Signs & Symptoms (missed dialysis).

Thanks.
 
Pt is a 40-year old gentleman who has dialysis Tues, Thurs and Saturday(timing) and was out of town for the holidays and was driving back (context). Unfortunately he was not able to make it to dialysis session, so he missed Tuesday (modifying factor), also Wednesday and then came in on Thursday (duration) with shortness of breath(location or associated sign and symptom) to the Emergency Room.

This is assuming you have a chief complaint somewhere else.

Just my take on it,

Laura, CPC, CEMC
 
OMG - Thanks so much Laura. I am just CLUELESS today -- its my first day back from having surgery and it seems like I don't know what I'm doing today.
 
Complaint is Shortness of Breath

I'm hoping the chief complaint is listed elsewhere ... but it seems that the reason he is in the ER today is SOB ...

I get:
DURATION (Tuesday, and Wednesday)
CONTEXT or MODIFYING FACTOR (he missed dialysis)
LOCATION (inferred from shortness of breath)

I would not count the fact that he usually has dialysis on Tue, Thur & Sat as timing because I don't think he's in the ER for renal failure, but for SOB.

***********

However, if his chief complaint IS Renal failure, then ...
MOD FACTOR - dialysis Tue, Thu, Sat
CONTEXT - missed dialysis
DURATION - Tuesday & Wednesday
LOCATION - kidneys (inferred from dialysis)
ASSOC SIGN - shortness of breath

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
This is the ER visit? I read it as a follow up after the ER visit most likely with the nephrologist. I guess I misunderstood.

Laura, CPC, CEMC
 
Helps to be clear

Laura ... I re-read it with your assumption that it was a follow-up and I can totally see how you got that.

So much of this E/M business is open to interpretation ... It really helps to have a clear picture of the situation.

F Tessa Bartels, CPC, CEMC
 
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