Everything you chart stems from the chief complaint and the history of present illness (HPI). This means that whatever is documented in the subjective portion of your chart needs to be addressed in the following review of systems (ROS), objective (physical exam, labs, etc.), assessment and treatment plan. If it is not, your chart is incomplete and is now open to litigation. Everything flows down from the HPI.
It is vital you understand this if you want to cover your ass with your documentation. There are two trains of thought with charting:
- Charting everything and covering every angle of the encounter.
- Charting less and keeping the chart simple and straight to the point.
Check out the blog post about charting less for more information. It is my opinion that less is more with charting, but I understand the argument for charting everything as well.
When your chart is very thorough, it addresses everything that is included in the chief complaint and HPI. So, if you write a lengthy HPI, you are going to need to back up everything in the rest of your note.
On the other hand, if your HPI is short and straight to the point, you only need to address those points in the rest of your note.
Does that make sense? If not, reread the last 2 paragraphs.
Of course, you should be covering everything that is relevant to the complaint in your HPI, but often times, if it is a relatively straight forward complaint, why document more than is necessary?
I see lengthy notes with very detailed HPI’s for simple complaints such as a cold or a sprained ankle from other providers. I scratch my head and ask why? Why give yourself more work? Why open yourself up to more liability? Keep the note simple! The more you include in the HPI, the more you need to address in the rest of your note.
Of course, when you accept insurance in your practice, you have to chart to meet the insurance overlords requirements if you want to get paid. They like those pretty perfect notes! When you are a cash practice, you can chart as you wish.
Let’s look at a few examples of short and long HPI’s:
- Chief complaint: cough and congestion.
- Short HPI: Complains of cough and congestion x 3 days. Denies fever, sore throat. Taking OTC meds with mild relief. Symptoms worsening.
- Long HPI: Patient presents complaining of productive cough, head congestion, rhinorrhea over the past 3 days. Denies fever, sore throat, wheezing, headache, nausea and vomiting, and otalgia. Comments he also has chest pain with cough and deep breaths and feels short of breath. Has been taking Delsym and Mucinex as directed with little relief. States the cough has been worsening over the past 48 hours.
The short HPI is straight to the point. The long HPI is filled with a lot of information. Ask yourself, is this information necessary? You documented chest pain and SOB. Are you prepared to back up those comments in the rest of your note? You better consider doing an ECG. Chest pain is documented, a cardiac etiology should be ruled out. Look through the lens of a lawyer when you are documenting. Is the long HPI really necessary? Is all the additional information necessary?
- Chief complaint: ankle pain after twisting it.
- Short HPI: Twisted right ankle yesterday, complains of lateral ankle pain. Denies neurovascular or functional deficits. Able to bear weight. Taking ibuprofen with moderate relief. Pain improving.
- Long HPI: Twisted right ankle yesterday playing basketball. States he jumped for the ball, landed wrong and fell twisting his ankle. States it was painful after the injury. States the pain is laterally and worse with flexion, ambulation, and when he puts his shoes on. Denies numbness, tingling, weakness, discoloration, deformity. Has been taking 400mg ibuprofen with moderate relief in the pain. The pain has improved since taking ibuprofen. States he can bear weight but must walk slowly to do so. States he needs his ankle to improve so he can play in a game in 2 weeks.
The short HPI has all the relevant information needed. The long HPI is filled with a lot of information that does not change the outcome. Both cover yourself medicolegally.
It is important to cover yourself within your HPI but look at it form a lawyer’s standpoint. Sometimes to much information will dig yourself into a deeper hole. The above examples were for simple complaints, but you should get the idea.
I believe keeping it short and simple is better in most cases. When you are dealing with more serious complaints such as severe headache, chest pain, abdominal pain, hypertensive urgency or neurological deficits, then you need to cover yourself thoroughly in your HPI.
The ROS comes next. You MUST ensure your ROS matches your HPI. I have seen countless charts where nausea was documented in the HPI and then it says negative nausea in the ROS. This throws the legitimacy of your chart out the window in court.
Also think very hard with what you document in the ROS. Is it relevant? Is it accurate? I love when I see “Negative: headache” or “Negative: tingling” in the ROS of a 9-month-old infant. The infant divulged that she didn’t have a headache and tingling? You were dealing with a very advanced verbal infant then! Be careful with what is in your ROS.
Make sure the objective component of your chart covers relevant systems that were documented in the HPI. If you document nausea and vomiting, you better document an abdominal exam. If you document headache, then there should be some sort of neurological exam documented. Ensure your physical exam, labs and radiological studies cover what was documented in the HPI and ROS!
In terms of your assessment and plan, you need to make sure that what was documented in the HPI, ROS, and objective section is consistent with your diagnosis. If a patient presents with strep but has a BP of 160/95, make sure you document hypertension and in the plan you either addresses it or told them to follow up with their PCP. It is very important that the data in your HPI, ROS, and objective section are addressed in the assessment and plan. If they are not, your chart is not complete.
This is the flow of charting for simplicity purposes:
HPI information -> matches your ROS -> relevant systems are addressed in your objective section (physical exam, labs, etc.) that correlate with the information in your HPI and ROS -> your assessment covers all the data from your HPI, ROS, and physical exam -> the plan addresses every finding in the rest of your note.
It all starts with the HPI. Whatever is documented, needs to be addressed. Be careful, too much information sometimes is not the best course of action like we were led to believe in nursing school. In my opinion, I think keeping it simple and relevant is the way to go when you write that HPI. If you want to remain being an elite nurse practitioner, then make sure you cover yourself so you can keep practicing!