Class 3 Flashcards
What is the first information a physician discuses with a patient?
their subjective information
Chief complaint, HPI, ROS
Should a chief complaint be included in the HPI?
Yes, always
What do you need to make sure the chief-complaint is for billing reasons?
something specific
Fix “check-up” for billing
…. management visit
Fix “follow-up” for billing
… management evaluation
Fix “lab results” for billing
Discuss treatment plans for …
Fix “medication refill” for billing
Evaluation of medical management of …
How is the ROS phrased?
In terms of positives and negatives
The ROS does not include context
What are the eight elements of the HPI?
Onset, timing, location, quality, severity, modifying factors (positive and negative), associated Sx, context
Is the Chief Complaint an element of the HPI?
Not technically an element but needs to be included
What should always be the beginning of the HPI?
the age/sex of the patient and chief complaint
What form should the HPI be in?
complete sentences
What is always relevant in the HPI?
answers to EVERY question the doctor asks
If patient says “It started Monday”
Symptoms began 3 days ago
If patient says “It got better”
Sx improved
If patient says “I took Tums and it didn’t help”
Sx were unchanged by Tums
If patient says “I have lower back pain, but I always have that”
Patient has chronic lower back pain, unchanged from baseline
If patient says “It hurts when I touch it”
Pains are worsened by palpation of the area
If patient says “Nothing makes it better or worse”
There are no modifying factors
If patient says “My sister has the same cold”
Positive sick contact with sister who has similar symptoms
If patient says “I throw up when I eat or drink anything”
The vomiting is exacerbated by PO intake
If patient says “It feels like a fizzing soda in my chest”
Chest pain is described as “fizzing soda” sensation
If patient says “I have the flu”
Pt has rhinorrhea and cough (do not document self diagnoses)
What is the most commonly used HPI structure”
the single complaint formula
When do you use the single complaint formula?
best for patients with only 1-2 complains that have not been previously evaluated
What is the structure of the single complaint formula?
1) age and sex
2) complaint and onset
3) quality, severity and location
4) modifying factors
5) positive associated Sx
6) pertinent negatives
7) other important context
Give an example of a standard HPI
43 y/o female c/o HA since 2 days ago. Pt describes a constant mild pressure behind the eyes. Pain is worse w/ bright light and unchanged by Advil. The pt also has associated nausea, but denies fever or weakness. Pt has had similar HAs in past.
When do you use the multiple complaint formula?
Patients who have multiple complaints, routine follow-up for chronic illnesses, different treatment plans for different complaints
Multiple complaint formula
Each complaint or disease is documented in a separate paragraph
When do you use the chronological formula for HPI?
best for complex stories
patients with multiple comorbidities, patient who have had a significant workup or evaluation in the past, established patients here for follow-up of a chronic illness
What is different about the chronological formula for the HPI?
You start with a chronological recap of relevant PMHx, previous evaluations and treatments
Then you move into complaints, elements, and context like a normal HPI
Example of how to start the chronological formula
86 y/o male with PMHx of COPD, HTN and HLD returns today.
Should the ROS and the HPI ever contradict each other?
No, since they are both subjective
Information that is found in the HPI and extra irrelevant information to chief complaint should be put in the ROS
Do you need to answer every check box of the ROS?
No, only use the boxes that the doctor specifically asks about
How is the ROS organized?
by body systems
Scribe attestation
Documented by Kate Appel acting as a scribe for Dr. X. Date/time
Constitutional body system in ROS
Fever, weight loss, sweats
Endocrine body systems in ROS
polyuria, polydipsia
Genitourinary body system in ROS
Dysuria, frequency, urgency, hematuria
How do you say “patient complains of” ?
Pt c/o
What is the abbreviation for headache?
HA
What is the abbreviation for “symptoms” ?
Sx
What is the abbreviation for “diagnosed” ?
Dx
What is the medical term for runny nose?
Rhinorrhea
What is the medical term for tingling?
Paresthesia
What is the medical term for muscle pain?
Myalgia
What does “onset” mean?
when the problem began
What does “timing” mean?
How often does the patient have their symptoms
Constant, intermittent, waxing and waningq
Difference between intermittent and waxing/waning
Intermittent: symptom comes and goes
Waxing/waning: symptom is always there but the intensity fluctuates
What does “quality” mean?
What does the symptom feel like? Is it aching? Burning? Etc/
Should pertinent negatives go in the HPI?
yes!
