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Chief Complaint

Michael Posted Mon 04th of May, 2015 14:19:21 PM

If the doctor states the patents Chief Complaint and then states that same problem again in the HPI can you count it in both places? Is it considered double dipping if it is clearly stated in both locations?

SuperCoder Answered Tue 05th of May, 2015 05:36:25 AM

When a chief complaint (CC) is being selected, you have to make the level of HPI by selecting rest of the elements (location, severity, quality, etc) related to that CC. For example, "Knee Pain" is CC, so out of it you can consider knee as location of pain, but taking "Knee Pain" as a whole does not make sense. So, out of CC you can snatch another element to contribute for HPI.

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