Psychiatric HPI

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

Moderators: NAMAS Moderator, Shannon DeConda

Psychiatric HPI

Postby Shoshana » Tue Jan 09, 2018 2:14 pm

Can anyone help me with the HPI elements in this? I am typing it verbatim with only redaction of identifying names.

"The patient is an 82 y/o white male, he reports that he lives alone has no family, supported by SS, single, he denies previous psychiatric history, no psychiatric hospitalizations, no suicidal attempts, with no past medical history who presented with altered mental status. Patient was initially very agitated and aggressive in the ER. Patient was sedated with Ativan IM by ER physician. Per Dr. XXXX, patient was found wandering in the bilateral mall parking lot. The police brought him in voluntarily basis initially. But, he was Baker acted posteriorly. Chart was reviewed. Case discussed with nurse in charge and PA Ms. XXXXXX. On psychiatric evaluation, patient is found calm, superfically cooperative, pleasantly disoriented and confused. He is malodorous, dirty, visibly self neglected. Patient says that he does not know what she is doing here. He does not know the reason he was brought to the hospital. Patient is unable to clarify were his living, or who is living with. He says that he wants to go home, but doesn't know his address. At the beginning he says that he is in XXXXXX, but minutes later he says that he liven in XXXXX. He reports good mood, he says that he is happy, denies suicidal and homicidal ideation, he denies visual and auditory hallucinations. Patient is disoriented in time and place. Able to repeat 3 words, but unable to recall the and 5 minutes later. He is able to list the days of the week, but he cannot do it backwards. Cannot spell the word world in any way. As per nursing charge, now the patient is quiet and calm, but before he was agitated, aggressive and wanting to leave the hospital and very disorganized."

I know there are ROS elements, exam elements and PFSH elements, but what are the History elements? I get quality and context. Maybe associated signs and symptoms. Also, would you give credit with discussion with other healthcare provider for data?
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
Shoshana
 
Posts: 39
Joined: Fri Jun 23, 2017 5:41 pm
Location: Hospital

Re: Psychiatric HPI

Postby Shannon DeConda » Tue Jan 09, 2018 4:10 pm

Associated S&S: Aggressive (While there is no CC specifically identified i think we could agree that he is agitated is at least somewhat of a chief complaint, and aggressive is a S&S of it)
MF; Ativan
There is no sated duration--- it seems implied it was within the past 24 hours, but because not implicitly stated we cannot use it, but this would have been a good one for them to have used
There is no stated severity, but had the provider identified the level of agitation or aggressiveness of the patient- this would have worked.

When working internally, please do not fail to remember that you could query the provider and request an addendum to a record requesting more of the history that we know they had at the time, but merely failed to include in the documentation.
Thank you,
Shannon O. DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CMPM, CPMN
Founder & President of NAMAS

Disclaimer: NAMAS cannot be held liable for any advice given that could have had a variable answer based on additional information.
Shannon DeConda
Global Moderator
 
Posts: 53
Joined: Thu Apr 12, 2012 6:53 pm
Location: Melbourne, FL


Return to Medical Auditing Forum

Who is online

Users browsing this forum: No registered users and 3 guests

cron