Basic Medical Coding

Step in History
How long have What part of Is the pain continous
you had the sore your throat ? Does it become
throat ? hurts better or worse ?

How does it compare Do you also What are you

to other sore throat have other doing when it
you have had ? symptoms ? hurts ?

How would you What have you

described the done to obtain relief
pain ? ? Did it work ?
 History of
Present
Illness (HPI)
Associated
severity signs &
symptoms
timing

location

duration
 Medical Coding
(Patricia Aalseth)

Review Of System
(ROS)

●
14 review of system
●
Dasar (BB, TB, Suhu, Pola Makan, Pola
Tidur) ●
Observe General appearence
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8 Kategori pertanyaan ●
Mata
for additional signs
●
Telinga, Hidung
●
Kardiovaskuler
●
Respirasi
●
Gastrointestinal
●
Genitourinary
●
Muskuloskeletal
●
Kulit
●
Neurological
●
Psychiatric
●
Endkrin
●
Hematologic/lympathic
●
Alergi
HPI Reality Check