Wiki Is this past medical history?

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codecrazy

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Followup visit for left buttock wound infection due to pseudomonas aeruginosa. She still has a small open wound over her left buttock area with
clear yellowish bloody drainage. She completed antibotic treatment last week. She was taking levaquin for pseudomonas wound infection. She also
denies having fever, chills, or night sweats.
 
I would consider that a modifying factor myself. Now the next piece stating she was taking levaquin I would be more inclined to call past history. I know it is semantics but I am more concerned about the ROS on this. I think you are stuck at EPF due to that unless there is an additonal ROS somewhere else.

Just my opinion,

Laura, CPC, CEMC
 
Detailed history

To get a detailed history ...
FIRST - you have to have 4 elements of HPI (or status of 3 chronic conditions, which doesn't apply in this case)
SECOND - you have to ALSO have at least 2 systems reviewed
THIRD - you have to have at least one item of Past history - medical, family or social.

I think your chief complaint is in your first sentence ... patient has been under treatment for wound infection due to pseudomonas aeruginosa So we have quality (small open), location (left buttock), Assoc symptom (clear yellow drainage) and Modifying factor (taking levaquin).

In this snippet from the note I only get a review of constitutional system (fever, chills, night sweats). You'd need at least one more before you'd need to worry about PMFSH.

BUT if you have more ROS somewhere, I would count "She completed antibotic treatment last week" as past medical history. Since Abx treatment wasn't directly related to treatment of pseudomonas.

Just my opinion.

F Tessa Bartels, CPC, CEMC
 
Hi,
I pretty much agree with Laura and F Tessa, but would caution against separating antibiotics from Levaquin as this medication is an antibiotic. The fact that the patient took it is a modifying factor as the drug had an impact (or at least was supposed to help heal) on the wound.
The fact that this therapy is completed may be considered past history, but I would be cautious. You don't want to use one item in more than one spot. Of course, if there is further pertinent detail on that item that's a different picture. Also, unless there is more detail in the note than given here, in particular the ROS, you will have an EPF history - so neither a fourth HPI nor the PH will change anything in this scenario.
 
Pmh

I agree with the last two responders.
But one thing is that as per the line "She completed antibotic treatment last week. She was taking levaquin for pseudomonas wound infection",i think antibiotic treatment here refers to the completed levaquin treatment.

Just my thought....
:)
 
How you read things

This is why it is so important to have clear documentation. When I first read the note I did NOT associate the two sentences. But on reading it again, I think you are right. The Levaquin was the antibiotic patient has been taking.

You still don't have enough ROS to even need past medical history, however.

F Tessa Bartels, CPC, CEMC
 
Thank you

This gets so complicated sometimes, luckily we can put our heads together and make sure its coded right. Thank you for your expertise.
 
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