Cc/hpi

My hospitalists will state "no complaints" or "patient feels well" or "no events overnight." Can I count that as either the chief compliant or part of the HPI???

re: CC/HPI

You only need 2 o3 f the 3 key elements if you have a subsequent E/M. I usually get an exam and MDM. Hospital records are running records. You can pull a few elements from another dos during the same stay, but only if you need to help this meet one of your elements. You could count "feeling well" as constitutional in your ROS. Your CC would be the reason this doctor is seeing the patient, like medication management, the complications of a condition like hyponatremia. It could also be the reason the patient came to the hospital if no other reason is found.

re: CC/HPI

I agree. Problem I am finding is that they rarely reiterate why they are inpt and being seen, so there usually is not a CC. As each note has to stand on its own, if all you get is "feeling well" or "no complaints" or "pt seen and examined at bedside," that really doesn't state why! The HPI ends up being short, as well as the ROS sometimes, which totally discounts the whole history portion. That is when the PE and MDM have to carry the code. Just wondered how others used those comments. Thanks very much for your reply. Time to educate them!