Context

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JJones
Posts: 42
Joined: Sat Dec 20, 2014 9:32 pm

Tue Jun 05, 2018 2:39 pm

Hello!

Thank you in advance for any help or direction.

If you can consider in HPI that exposure to Strep is context, can the reverse also be used for context - "No known exposure to strep"? The CC is a sore throat.

Thanks again,

J Jones
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admin
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Posts: 451
Joined: Mon Apr 09, 2012 1:54 pm

Wed Jun 06, 2018 1:23 pm

I think this is a gray area of context, but I would say that yes that would count as context.The reason I say this is the provider would not know what external factors are affecting the patient without asking. The information may affect the additional work up or treatment plan, I think the information is relevant even if the answer to their answer to the question asked is no.

Your question has been answered by Stephanie Allard, CPC, CEMA, RHIT
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