CC And HPI

Question 1

During the medical interview what are some things to consider?

Answer 1

1. Privacy
2. Minimize interruptions
3. Eye level, seating arrangement
4. Patient comfort
5. Mental status

Question 2

During the interview process what are some things to consider while talking to the patient?

Answer 2

1. Use open ended questions
2. Clarification and elaboration questions
   *More specific questions
3. Closed questions

Question 3

How to document the CC?

Answer 3

Document verbatim
*use quotes

Question 4

What is there is no CC?

Answer 4

Then why are they visiting the office
EX: “Everything is fine”, “I was told to come in”
*Open-ended questions can lead to the CC

Question 5

Is the apparent reason for coming into the office mean that its the actual reason for coming?

Answer 5

NO

Question 6

What is Iatrotropic Stimulus?

Answer 6

Reason why the patient decided to seek care at the particular point in time

Question 7

How to begin the History of Present Illness (HPI)

Answer 7

Sentence with
1. Patients initials, age, race, sex, and reason for visit
*can have additional info about PMHx if it pertains to the CC

Question 8

What creates the HPI?

Answer 8

OLDCARTS
Onset- when, has it occurred before
Location- where
Duration- how long has CC lasted, recent/chronic, worsening
Characteristics- CC descriptive words
Aggravating/alleviating- Better/worse
Radiation-Does CC move
Timing- Constant, comes and goes
Severity- pain scale

Question 9

Order of documentation

Answer 9

Date/Time
Identifying/verification data
CC
HPI
*OLDCARTS