Wiki Hpi help

klthompson

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Location
Camdenton, MO
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In the following HPI, I am unsure on the elements or chronic problems listed in the HPI. Any opinions would be greatly appreciated.

Reason for Appointment
1. Transfer from dr. XXXXXXX
2. No cardiac complaints, just needs refills of the following medications for 90 days + refills: ramipril 1.25mg, simvastatin 20mg, clopidogrel 75mg, isosorbide mono er 30 mg, metoprolol tart 25 mg, and nitrostat 0.4 mg.
3. Patient also c/o "intense hot flashes" since total hysterectomy 04/12.
4. XXXXXXXX LPN

History of Present Illness
Coronary Artery Disease:
Patient presents to establish further cardiology care as she is switching care from Dr. XXXXXXX denies any history of chest pain or shortness of breath.
She is known to have coronary artery disease status post myocardial infarction a year ago underwent successful patient stent of the left circumflex artery.
She also had a CVA three months ago which caused a memory loss.[/COLOR]
 
STATUS of three chronic problems

To claim the status of three chronic conditions for HPI vs the elements of the present illness, the provider must document the status... i.e. stable, improved, worsening.

You do not have such documentation in the example you cited, so you'll have to use elements.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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