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Scribe > Class 3 > Flashcards

Class 3 Flashcards

1
Q

What is the first information a physician discuses with a patient?

A

their subjective information

Chief complaint, HPI, ROS

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2
Q

Should a chief complaint be included in the HPI?

A

Yes, always

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3
Q

What do you need to make sure the chief-complaint is for billing reasons?

A

something specific

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4
Q

Fix “check-up” for billing

A

…. management visit

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5
Q

Fix “follow-up” for billing

A

… management evaluation

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6
Q

Fix “lab results” for billing

A

Discuss treatment plans for …

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7
Q

Fix “medication refill” for billing

A

Evaluation of medical management of …

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8
Q

How is the ROS phrased?

A

In terms of positives and negatives

The ROS does not include context

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9
Q

What are the eight elements of the HPI?

A

Onset, timing, location, quality, severity, modifying factors (positive and negative), associated Sx, context

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10
Q

Is the Chief Complaint an element of the HPI?

A

Not technically an element but needs to be included

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11
Q

What should always be the beginning of the HPI?

A

the age/sex of the patient and chief complaint

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12
Q

What form should the HPI be in?

A

complete sentences

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13
Q

What is always relevant in the HPI?

A

answers to EVERY question the doctor asks

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14
Q

If patient says “It started Monday”

A

Symptoms began 3 days ago

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15
Q

If patient says “It got better”

A

Sx improved

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16
Q

If patient says “I took Tums and it didn’t help”

A

Sx were unchanged by Tums

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17
Q

If patient says “I have lower back pain, but I always have that”

A

Patient has chronic lower back pain, unchanged from baseline

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18
Q

If patient says “It hurts when I touch it”

A

Pains are worsened by palpation of the area

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19
Q

If patient says “Nothing makes it better or worse”

A

There are no modifying factors

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20
Q

If patient says “My sister has the same cold”

A

Positive sick contact with sister who has similar symptoms

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21
Q

If patient says “I throw up when I eat or drink anything”

A

The vomiting is exacerbated by PO intake

22
Q

If patient says “It feels like a fizzing soda in my chest”

A

Chest pain is described as “fizzing soda” sensation

23
Q

If patient says “I have the flu”

A

Pt has rhinorrhea and cough (do not document self diagnoses)

24
Q

What is the most commonly used HPI structure”

A

the single complaint formula

25
Q

When do you use the single complaint formula?

A

best for patients with only 1-2 complains that have not been previously evaluated

26
Q

What is the structure of the single complaint formula?

A

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

27
Q

Give an example of a standard HPI

A

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.

28
Q

When do you use the multiple complaint formula?

A

Patients who have multiple complaints, routine follow-up for chronic illnesses, different treatment plans for different complaints

29
Q

Multiple complaint formula

A

Each complaint or disease is documented in a separate paragraph

30
Q

When do you use the chronological formula for HPI?

A

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

31
Q

What is different about the chronological formula for the HPI?

A

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

32
Q

Example of how to start the chronological formula

A

86 y/o male with PMHx of COPD, HTN and HLD returns today.

33
Q

Should the ROS and the HPI ever contradict each other?

A

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

34
Q

Do you need to answer every check box of the ROS?

A

No, only use the boxes that the doctor specifically asks about

35
Q

How is the ROS organized?

A

by body systems

36
Q

Scribe attestation

A

Documented by Kate Appel acting as a scribe for Dr. X. Date/time

37
Q

Constitutional body system in ROS

A

Fever, weight loss, sweats

38
Q

Endocrine body systems in ROS

A

polyuria, polydipsia

39
Q

Genitourinary body system in ROS

A

Dysuria, frequency, urgency, hematuria

40
Q

How do you say “patient complains of” ?

A

Pt c/o

41
Q

What is the abbreviation for headache?

A

HA

42
Q

What is the abbreviation for “symptoms” ?

A

Sx

43
Q

What is the abbreviation for “diagnosed” ?

A

Dx

44
Q

What is the medical term for runny nose?

A

Rhinorrhea

45
Q

What is the medical term for tingling?

A

Paresthesia

46
Q

What is the medical term for muscle pain?

A

Myalgia

47
Q

What does “onset” mean?

A

when the problem began

48
Q

What does “timing” mean?

A

How often does the patient have their symptoms

Constant, intermittent, waxing and waningq

49
Q

Difference between intermittent and waxing/waning

A

Intermittent: symptom comes and goes

Waxing/waning: symptom is always there but the intensity fluctuates

50
Q

What does “quality” mean?

A

What does the symptom feel like? Is it aching? Burning? Etc/

51
Q

Should pertinent negatives go in the HPI?

A

yes!

Scribe (6 decks)

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