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I have some confusion regarding the HPI. All of the examples seem to relate to various aspects of pain. If the patient has a lump/lesion without pain can the fact that this is a description of the problem count in the quality category. Also can the size of something count in the severity area. Lets say that the patient has a 5 cm lesion.
Does anyone have a site that gives more examples of HPI documentation (not so traditional examples). I have no problem if it is a painful situation, but we also treat lumps and bumps which require surgery, and they are not always painful, but we are discussing size, description lump/lesion. It is not always so clear if we are meeting the comprehensive category when the rules do not seem to clarify conditions that are described that are not painful.
Thanks,
Dee
Does anyone have a site that gives more examples of HPI documentation (not so traditional examples). I have no problem if it is a painful situation, but we also treat lumps and bumps which require surgery, and they are not always painful, but we are discussing size, description lump/lesion. It is not always so clear if we are meeting the comprehensive category when the rules do not seem to clarify conditions that are described that are not painful.
Thanks,
Dee