CatchTheWind
Guest
I know this is an old question, but I am drawing a blank:
Does the HPI have to be strictly what the patient tells the physician, or can it include the provider's observations, as well? For example, in describing a skin lesion, does the patient have to state that the lesion looks red and scaley, or can the provider's observation of this fact be included in the HPI?
Does the HPI have to be strictly what the patient tells the physician, or can it include the provider's observations, as well? For example, in describing a skin lesion, does the patient have to state that the lesion looks red and scaley, or can the provider's observation of this fact be included in the HPI?