Wiki hpi

[alices]

I know I've asked this question before so sorry for asking again I can't find original answer,
when a pt comes to the ER and the dr writes for the hpi left sided chest pain, but no other comlaints, no loss of conscious, no headaache are the negatives allowed also? i mean can i have location, and use the no loss of conscious or no headache as an asso sign ?..thank you, alice

 

[Naveen Rachagolla]

Hpi only location

You cannot use the other terms what you mentioned that no loss of conscious, no headaache if these two are happened or occured because of the pain in chest and if Dr writes in the notes then only you can use as AS&S.

More over you can use these two no loss of conscious, no headaache to extract ROS if Dr writes this statement in the notes or in the patient medical record.

 

[FTessaBartels]

Negatives signs / symptoms

I definitely would count pertinent negatives in associated signs/symptoms. So if a patient presented with chest pain and physician noted no LOC or no headaches, I might consider that related.

Otherwise, I would include the statement as part of ROS.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[alices]

re-hpi

Thank you for the help, so if I am understanding right, I can not use the no loc or no headache in the hpi for assoc/signs and symptoms? I don't need any in my ros that is complete..thanks, alice