Wiki HPI elements - abdominal bloating

[ajfinn0216]

I just wanted to get another perspective on this:

Patient presents for follow-up of heartburn. This has been associated with abdominal bloating, fullness after meals and midepigastric pain. Symptoms have been present X 2 days. Medical therapy in the past has included Protonix.

I count the following as HPI elements:

location: chest area (heartburn)
duration; 2 days
associated signs and symptoms: abdominal bloating, fullness and midepigastric pain

I am being told the Protonix should be counted as a modifying factor. I do not agree. Simply stating that it has been tried in the past would make this a statement of past history not a modifying factor.

In all my years of doing this, I was under the impression that in order to count something as a modifying factor that there should be some indication as to whether or not that therapy tried affected the complaint. I do not believe that you can elicit from the statement made that Protonix had been tried in the past that it did not help with the present complaint.

Thanks for any comments

Angie

 

[jimbo1231]

After Meals

Would it be too much of a stretch to count "after meals" as context? Probably too much of a stretch since fullness is an Ass. sign not CC. But I think one could argue with an auditor that after meals was the context for these GI symptoms. But probably better is the provider stated that context of heartburn is after meals...or after a spicy meal if that is the case (at least it is for me).

Jim

 

[drashby]

Angie,

I agree with you that simply stating that is was tried without further explanation as to whether it helped or did not should not be counted as MF. Since you don't know if the patient tried it yesterday or 10 years ago. But I like that you counted it under PFSHx.

dra