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https://en.wikipedia.org/wiki/History_of_the_present_illness
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain
https://quizlet.com/45414007/the-medical-record-flash-cards/
Th circumstances surrounding the onset of the chief complaint (i.e. pain began while mowing lawn, vomiting began after eating an old burrito) Associated Symptoms Symptoms that are directly related to the chief complaint.
https://www.aao.org/young-ophthalmologists/yo-info/article/em-documentation-requirements-part-3-chief-complai
Jul 22, 2014 · The chief complaint does not have to be documented in the patient’s own words unless it provides helpful information, such as in the complaint of dry eyes: Eye discomfort OU X 2 wks. Feels like “crushed potato chips.” Artificial tears and ointments no lasting relief.
https://www.quora.com/What-is-the-difference-between-a-chief-complaint-and-an-associated-symptom-when-taking-medical-history
Mar 14, 2019 · You find about them when talking about the chief complaint in detail or sometimes patients mention themselves that the chief complaint is accompanied with some other symptoms. For eg. fever is a chief complaint which can be associated with shivering, diurnal variation, lack of appetite etc.
http://www.dralisonchen.com/2012/02/assessing-chief-complaints/
Let’s go through an example Chief Complaint of BACK PAIN: L- location: left lower back pain (sacroilliac region) along the vertebrae and left erector muscles O- onset: started 2 weeks ago when I was cleaning out my garage and lifting heavy boxes.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2850833/
There was a low level of background “pneumonia symptoms” chief complaint as interpreted by the triage nurse, which poorly follow the trends for ILI. However, pneumonia diagnoses for our data peak at week 6 with 25 patients, followed by week 18 with 23 patients; week 8 …Cited by: 16
http://wps.prenhall.com/wps/media/objects/5616/5750791/opqrst.pdf
prior to and during the onset of the specific symptom(s) or chief complaint. • What were you doing when the symptoms started? • Was the onset sudden or gradual? It may be helpful to know if the patient was at rest when the symptoms began or if they were involved in some form of activity.
https://www.healthicity.com/hubfs/healthicity/Resources/eBriefs/history_is_key/Healthicity_EBrief_HistoryKey.pdf
2. The chief complaint is the pa-tient’s presenting problem. “Fol-low up” is not a chief complaint. 3. If the patient doesn’t have a problem (for instance, she just needs an annual exam), there is no chief complaint. You must bill a preventive E/M service. 4. Every encounter must have a mini-mum of one HPI or the status of at least
https://quizlet.com/421483553/chief-complaint-flash-cards/
Expressed in Pack years- A person who has smoked 1.5 packs a day for 12 yrs = 18 pack-year history. If someone has quit note how long a ago. Record info on smokeless tobacco use- Their use involves chewing, sniffing, or placing the product between gum and the cheek or lip.
https://www.ophthalmicprofessional.com/issues/2016/july-2016/refine-your-history-taking-skills
Jul 01, 2016 · “It [the ‘cheat sheet’ or poster] should contain chief complaint, the eight quantifiers — location, duration, timing, etc. — past ophthalmic history, general medical history, personal, social family history and the number of items that must be included/documented in order for the exam to qualify at a specific level of billing.
https://www.supercoder.com/coding-newsletters/my-part-b-coding-alert/em-coding-make-sure-your-doctor-lists-a-chief-complaint-article
Aug 18, 2006 · No symptoms doesn't mean no reason for the patient to be there If your doctor is in the habit of marking -patient has no complaints- or -asymptomatic- on documentation, then you may have a big problem of your own. The problem: Every Medicare visit must have a -chief complaint,- or the main reason why your physician is seeing the patient.
https://www.mayoclinic.org/diseases-conditions/obsessive-compulsive-disorder/symptoms-causes/syc-20354432
OCD usually begins in the teen or young adult years. Symptoms usually begin gradually and tend to vary in severity throughout life. Symptoms generally worsen when you experience greater stress. OCD, usually considered a lifelong disorder, can have mild to moderate symptoms or be so severe and time-consuming that it becomes disabling.
http://www.lumen.luc.edu/Lumen/meded/elective/pulmonary/copd/120699/case2.htm
Chief Complaint: "I'm short of breath; I can't stop coughing." History: Mr. O'Connor is a 62 y/o auto mechanic who presents with progressive shortness of breath for the past several days. His problem began four days ago when "I got a cold". His "cold" consisted of a sore throat, rhinorrhea and myalgia.
https://www.aapc.com/blog/23875-8-tips-for-compliant-history-component-documentation/
The chief complaint is the patient’s presenting problem. “Follow-up” is not a chief complaint. If the patient doesn’t have a problem (for instance, she just needs an annual exam), there is no chief complaint. You must bill a preventive E/M service. Every encounter must have a minimum of one HPI or the status of at least one chronic illness.
https://www.michigan.gov/documents/mdch/Pediatrics_Scenarios_441050_7.pdf
Chief Complaint: Fever and cough HPI: The patient is a 10 year-old girl being seen for the acute onset of fever, nonproductive cough, myalgia, and arthraligia. She denies difficulty taking a deep breath.
https://www.urmc.rochester.edu/medialibraries/urmcmedia/compliance-office/education-tools/compliance/documents/emdocumentationtips4-08.pdf
Evaluation and Management Documentation Tips URMC – Compliance Office – 4/08 1 . Chief Complaint (CC) DO DON’T . Specify reason for the visit • “Patient presents for follow-up evaluation of ankle sprain.” Fail to specify reason for visit • “Patient presents for follow-up.” Specify who requested a consult and why • “
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3859191/
When a patient presents with both psychotic and obsessive-compulsive symptoms, the clinician is faced with a differential diagnosis that includes comorbid schizophrenia and obsessive-compulsive disorder (OCD), OCD with poor insight, and schizophrenia with antipsychotic-induced obsessive-compulsive symptoms.Cited by: 19
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