Wiki HPI elements !!!!!!

[NishaJ]

Hi Anyone help me to count the HPI elements...
25 yr old female presents with c/o Alopecia Unspecified, Site: Scalp, , patient reports improvement as:, mild, patient reports improvement with previous IL TAC injections, patient admits to compliance with medication. c/o Post-Inflammatory Hyperpigmentation (PIH) Site: neck. patient states no improvement is compliant with body lotion 15% would like to continue regimen. c/o Seborrheic Dermatitis site: scalp, . c/o Xerosis Site bilateral arms and legs.

Can we consider this conditions Post-Inflammatory Hyperpigmentation \Seborrheic Dermatitis \Xerosis for ASSOCIATED SIGNS AND SYMPTOMs..
Because I have heard like Confirmed diagnosis \conditions cannot be counted as an associated sxs. Only symptoms can be counted here.

Any suggestions...

 

[Kris Cummings]

I think you need a good description of what each of the HPI elements mean. Once you get that down, you'll feel better about determining HPI elements altogether. For the HPI you describe, here's what I find:

CC: Alopecia, PIH, Seborrhea Dermatitis and Xerosis.

Locations: Scalp, Neck, Bilat Arms/Legs
Quality: mild improvement/no improvement
Modifying factors: Compliant with medication, body lotion and prior injections gave improvement

Associated signs and symptoms for patients with these type of conditions could perhaps be itching, swelling, redness, etc... but not the conditions themselves, they are the chief complaint(s) and the reason the patient is being seen.

Here's a link to Health Care Compliance Associations Audit Manual for E/M Services. You'll find the HPI elements described on page 2: http://www.hcca-info.org/Portals/0/PDFs/Resources/library/Audit Manual.pdf

Good luck!

 

[NishaJ]

Thank you kris..

 

[Kris Cummings]

You're welcome, Nisha.