Wiki HPI duration question

[Tonyj]

Pt being seen for ongoing follow up of cancer and chemotherapy. In the HPI the physician states "since last visit pt has no new complaints" Could that comment be used as duration for HPI or is the duration considered the cancer which is being treated?

 

[rthames052006]

I have something here in a binder, but I am not sure the "source" but it says for Quality:

"Characterized by the sensation the patient is experiencing. For follow up problems doing well since last visit"

 

[annettehai]

I would qualify that statement in the chart as a pertinent negative under associated signs and symptoms. Has the physician stated what the "old" complaints were and that they still persited, then I would count that as duration.

 

[Tonyj]

I have something here in a binder, but I am not sure the "source" but it says for Quality:

"Characterized by the sensation the patient is experiencing. For follow up problems doing well since last visit"

I have E/M coding tool for history stating Quality: description or characteristic of a problem or symptom. Ex; yellow clear drainage, dull/sharp/radiating/throbbing pain, itchy rash...That being said I don't think I'd use use it for quality.