Wiki Impression from HPI Question

[Tonyj]

Physician states "HPI well characterized in my initial consult note dated xx/xx/xxxx." Then proceeds to document current HPI. My question is, can I use what was documented in the initial date of service in my diagnoses for future dates of services? e.g. Pt has history of breast cancer. It's not mentioned in the current note but is mentioned in the initial consult. Does he need to mention history of breast cancer in every note in order for me to include it as a diagnosis.

 

[aimie]

hpi

Did the dr reference the initial note then u can count it or did he reference the progress the pt is making w/breast cancer

 

[Tonyj]

Did the dr reference the initial note then u can count it or did he reference the progress the pt is making w/breast cancer

He only mentions it in the initial consult, never again in the follow up visits that he is treating for something entirely different. That being said, I was wondering if I could include all history codes from the initial consult onto the diagnoses for follow up care?