CC. Chest pain
HPI. Pt complains of chest pain for 2 hours, crushing in nature and pt feels short of breath.
Location, Duration, Quality, Associated Signs and Symptoms
CC. Chest pain
HPI. Pt complains of chest pain for 2 hours, crushing in nature but pt denies shortness of breath.
Location, Duration, Quality, Associated Signs and Symptoms.
As long as it is a pertinent negative response WPS Medicare says it is correct to count it for HPI.
Another example.
CC. Leg pain
HPI. Pt complains of Rt leg pain that is throbbing in nature for 2 days, fell down the stairs.
Location, Quality, Duration, Context
CC. Leg pain
HPI. Pt complains of Rt leg pain that is throbbing in nature for 2 days, no known injury.
Location, Quality, Duration, Context.
Hope this is helpful,
Laura, CPC , CPMA, CEMC