Wiki Need Another Coder's Opinion

[klamm]

What level would you give this HPI?



67 Y/O Female

Stools now mostly firm. Had some episodes of "bubbling" in her abd, then sudden watery stool.

Sugars are up - as high as 400. recently missing doses of insulin. Reports family problems - son and his family were evicted and had to move. Som also w/CHF. Helped them pack/move. Eating off diet. Missing evening insulin

Lt. knee pain - treated at OSH, Injections. some short term help but did not persist.

Chronic Medical Problems
HTN
DM
CAD


I really appreciate any opinions.
Thanks
KLamm

 

[jmwallen]

jmwallen

extended

 

[klamm]

That is the same level I came up with.

I'm being told that I could use ""Bubbling" in the stomach" as a GI ROS and use "Sugars are up" for a ENDO ROS, which would make this a Detailed HPI.

That seems like a stretch. Does anyone know if there are any specific guidelines on how to pick what can be used for the ROS and what can't be used?

Thanks
KLamm

 

[LLovett]

There are only 2 levels of HPI, Brief and Extended.

What is your chief complaint? Depending on what that is, this history could be go in different directions.

Laura, CPC, CPMA, CEMC