by admin » Wed Jan 17, 2018 4:04 pm
This is not as simple as Yes or No. The HPI is the history of the present illness, and can be abstracted from anywhere in the flow of documentation (exam is tricky, as objective observations are hard to separate from the patients subjective history). That being said, it still has to say how each condition was before the patient was evaluated, even if its located in the portion of the documentation listed as the assessment and plan. So if the provider only shows the patients condition AFTER EVALUATION, then no, it is not supported. IF the A/P has both the before (patients perspective) and the after (providers perspective), then yes.
Your question has been answered by Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC