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Old 07-11-2012
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Question documenting new patient note

Hi all:

When we are documenting new patient note, if today it is chest pain case. I have chest pain findings both in HPI and Physical exam, then in this case where should i document the pain in the note for differential diagnosis? In HPI findings part or physical findings part?

Thank you!
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Old 07-11-2012
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If the patient tells you it is part of HPI if you palpate and it illicits pain it goes in the PE so technically speaking it can end up in both sides, only on the PE side you would likely want to write it as tenderness to palpation of xxxx (where xxxx is the location of pain). Even though you can fill up to 8 rows in each side that does not mean you have to. Sometimes only 1 or 2 things will be all that point to a diagnosis.
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