Wiki How many elements do you see?

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ldadams50

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I understand that the HPI should be subjective, right? Therefore, how many elements do you see?


followup cavitary MAI. Ms **** is scheduled for an Infuse-a-Port. She'll have a right upper lobectomy in January. She has no high fevers, chills or chest pain. She had fever and we discontinued her PICC line pending her Infuse-a-Port. She has not had amikacin in a week. She still has intermittent problems with IBS and diarrhea.


Thanks for your input!!
 
I see 2 elements of HPI.

She has no high fevers, chills or chest pain. She had fever and -- use this for associated signs or symptoms. "what the patient has or does not have"

intermittent problems with IBS an-- "intermittent for timing" & w/IBS and for associated signs and symptoms. You would still get 2 elements. either way.
 
Thank you beforak1 and Gjackson for your responses.
Yes 2 definitely, signs & symptoms and modifying factors (because she has not taken the amikacin) But now I have 2 other questions.
1. Can cavitary MAI be used for 'location' ?
2. Can intermittent be counted as 'timing' because that is relevant to the
"other signs & symptoms' and not directly to MAI, right or wrong?

This isn't a test, I just don't know. I have decided that, the more I learn the more questions I have. :eek:
 
Last year, I had an auditor tell me that I could use the chief complaint the physician has stated as the location, so that is what I have been doing. I hope this is ok. However- to me-it seems like "double dipping." For example, our doctors often state the chief complaint is right knee pain. The auditor said I could use knee as the location. I feel that the location would be if they say exactly where it hurts in the knee. Is it the knee cap, behind the knee, in the knee joint, etc...? So, I do look for the exact location of the pain and use that as a point for the location, but if they do not state exactly where it hurts then I have been instructed to use right knee as stated in the chief complaint also as a point for location.
I'm still just an apprentice and want to do things the right way, so please let me know your thoughts on this. Thank you.
 
jeskla said:
Last year, I had an auditor tell me that I could use the chief complaint the physician has stated as the location, so that is what I have been doing. I hope this is ok. However- to me-it seems like "double dipping." For example, our doctors often state the chief complaint is right knee pain. The auditor said I could use knee as the location. I feel that the location would be if they say exactly where it hurts in the knee. Is it the knee cap, behind the knee, in the knee joint, etc...? So, I do look for the exact location of the pain and use that as a point for the location, but if they do not state exactly where it hurts then I have been instructed to use right knee as stated in the chief complaint also as a point for location.
I'm still just an apprentice and want to do things the right way, so please let me know your thoughts on this. Thank you.
Click to expand...

You would only be able to use the knee pain once. Either for the location or for the CC.
 
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