Wiki Nephrology HPI

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slswain

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This is more an auditing question. My questions involves the HPI for a nephrologist. The pt reason for visit is f/u for CKD. The pt has not complaints but the labs and pt has to be checked regularly and monitored. What would be considered the HPI? Labs were reviewed and new ones ordered to establish the severity and if the pt is stable or worsening and tx options. I am having difficult figuring how the HPI would be marked if the pt didn't have any physical complaints and the pt's labs were documented along with the list of their current problems but no known apparent problems at that time. Any insight would be greatly appreciated.:confused:
 
So it sounds to me like you'd have location and assoc signs and symptoms ( no complaints).

In the example you've given you'd have a brief HPI. I'm sure it will vary from pt to pt based on how the patient is doing at the present time if any complications etc.
 
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