Wiki Need HPI Help for Preemies with ROP!

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rattyvonratkins

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I've been trying to research HPI documentation tips for newborns with Retinopathy of Prematurity. The provider is wondering why I keep down-coding her IP visits and it's because I don't think her documentation meets History requirements for an initial exam, let alone initial L2 or L3. In particular, the HPI is troublesome since there are no visible symptoms for ROP, let alone specific complaints from the patient! Can anyone share how they document comprehensive-level HPI for newborns with ROP?

This is a typical HPI example from one of this MD's chart notes. Is there any advice I can offer this provider on how to expand on HPI for newborns who have no discernable, outward ROP symptoms? Or if I'm the one who's missing something/misunderstanding, please let me know. Thank you in advance!

INFANT INFORMATION
Gestational Age: 25w2d
Current Age: 47 days
Birth Weight: 690 g (1 lb 8.3 oz)
Apgar 1 minute: 4
Apgar 5 minute: 5
Delivery Type: C-Section, Classical

HPI
Prematurity; at risk for Retinopathy of Prematurity based on gestational age and birth weight
 
This is a screening for retinopathy, with the chief complaint being the prematurity, not necessarily treatment for the ROP, but the documentation surely could use a boost. You have barely enough information for a brief HPI, but since this is a screening, would this be a well-baby check? Did she diagnose the retinopathy? Is there any language in the assessment and plan that would meet HPI elements (sometimes doctors write their notes like that). Here's an article from the American Academy of Pediatrics that discuses and examination for these kids. Perhaps you can put together a template to help your provider obtain all of the necessary elements of the examination.
 
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