_______ a report or observation of evidence of pathology or ...

[folubunmi]

_______ a report or observation of evidence of pathology or disease in their own physiology, such as blood in urine, and/or subjective observations of physical experience such as pain or discomfort
 
  Fill in the blank with correct word.

Question 2

1. How does documentation of the HPI improve the quality of medical documentation? How would the absence of HPI impact the medical documentation of an E/M service visit?
 
  What will be an ideal response?

[wtf444]

Answer to Question 1

associated signs and symptoms

Answer to Question 2

Answer should include the following:
 HPI informs the performing physician on the patient's personal experience of the CC. Because the HPI is a personal, sometimes visceral description of the patient's CC, the performing physician is able to hear the patient's voice, notice intonation, identify any nonverbal cues during the patient's personal description of the CC. Because of the patient's personal description of the CC, the performing physician is able to ask the questions that are most pertinent to the CC, thereby providing a clinical background on the patient's CC.
 If the HPI were absent, there would be no personal description of the CC, thereby requiring the documentation to reflect merely the overarching symptom without any specific or clarifying information. For instance, a headache would simply be pain in the head, but without any indication of where in/on the head.

[folubunmi]

Thank you

[wtf444]

Happy to help you