dballard2004
True Blue
I have a question regarding HPI that I would like opinions on, please.
I am auditing for an orthopaedic/sports medicine provider, and when patients present to the office to be seen, they fill out a form where they note the reason they are seeing the doctor, what they have done to date for the problem, their past medical, family and social histories, etc.
On this chart in question, the patient notes on this form info regarding the chief complaint that would be considered HPI (i.e., modifying factors, associated signs/symptoms), but the provider does not mention this info in his dictated HPI. For example, the patient outlines what they are doing to date for the chief complaint (i.e., modifying factors) and other signs/symptoms that are occuring with the chief complaint, but the provider fails to mention any of this info in his dictated HPI.
In the chart, the provider does acknowledge that he has reviewed this form.
My question here is, can I use this info supplied by the patient as HPI even though the provider omits it in his dictated HPI?
I have read the E/M guidelines and they seem to indicate that the provider acknowledging the patient form really only applies to the ROS/PFSH section of the history.
Thoughts?
Thanks.
I am auditing for an orthopaedic/sports medicine provider, and when patients present to the office to be seen, they fill out a form where they note the reason they are seeing the doctor, what they have done to date for the problem, their past medical, family and social histories, etc.
On this chart in question, the patient notes on this form info regarding the chief complaint that would be considered HPI (i.e., modifying factors, associated signs/symptoms), but the provider does not mention this info in his dictated HPI. For example, the patient outlines what they are doing to date for the chief complaint (i.e., modifying factors) and other signs/symptoms that are occuring with the chief complaint, but the provider fails to mention any of this info in his dictated HPI.
In the chart, the provider does acknowledge that he has reviewed this form.
My question here is, can I use this info supplied by the patient as HPI even though the provider omits it in his dictated HPI?
I have read the E/M guidelines and they seem to indicate that the provider acknowledging the patient form really only applies to the ROS/PFSH section of the history.
Thoughts?
Thanks.