Wiki HPI Elements for E/M level of care

[Freitag17]

When reviewing a physicians documented HPI and you are counting how many elements they have to reach that higher level, would you count "Has not tried medications prior to coming here" for the signs and symptoms elements or "Patient denies shortness of breath, fatigure, etc". as a modifying factor element? They do address this with the patient, they just deny having these. It throws me off when the physician is missing just 1 of those elements to receive the higher level.

THANK YOU

 

[nomerz]

Sorry, having a little trouble following... if the patient is presenting for SOB, fatigue and it says that they have denied taking meds prior to presenting, I would count it as a modifying factor, as they are denying that they've done anything to make the symptoms better.