Hyperlipidemia Subjective / HPI

When a patient presents for her cholesterol follow-up visit you want to know what medications the patient is taking. Your dot phrase or smart phrase should include a list of the medications you usually prescribe. Statins are the usual medications indicated to treat dyslipidemias, but patients may also be using fenofibrate or newer medications like ezetimibe. Then you want to know if the patient has been compliant with the treatment. Followed by the report of any episodes of side effects like myalgias.

Another good thing to always review with the patient is lifestyle changes that can improve her hypercholesterolemia, like exercise and healthy diet.

Hyperlipidemia Objective / Physical Exam

Do you need really need to do a physical exam for a patient presenting with high cholesterol? Only when pertinent.

Hyperlipidemia Assessment and Plan

For accurate clinical documentation, always specify if the condition is stable/controlled or uncontrolled. Outline your plan. Whether it is to continue the same medications, change them, or work on lifestyle interventions.

The risk for cardiovascular disease (CVD) events in a patients should be calculated prior to starting statins. A risk >10% is considered the threshold to start medical therapy. However, any patient with history of atherosclerotic cardiovascular disease (ASCVD) like coronary artery disease (CAD) is considered high-risk and should be taking statins.

Ordering a lipid panel once a year to monitor the LDL can help to assess the adherence to medication and diet.

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