It is expected that testing facilities will not routinely modify diagnostic test orders from the ordering physician. Although diagnostic test orders may conditionally request an additional diagnostic test, the conditional request must come from the ordering physician. New orders must be obtained when a test is determined to be clinically inappropriate or suboptimal, or when […]
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HPI element : Modifying Factor
Does alleviation or aggravation of treatment tried be documented to count against Modifying factor?
Example:
Patient is a 58-year-old Caucasian female with sore throat, headache, chills and fever for past 3 days. Pain is rated as 5/10 on pain scale. Patient is experiencing dull pain. She tried lozenges yesterday.
Per my understanding, HPI elements are Duration, severity, associated symptoms and quality. Please correct me if I am wrong.
My question here is patient has tried lozenges, however, no relief is documented. Can I count this against modifying factor?