Class 3 - History of Present Illness Flashcards
Difference between subjective and objective information.
Sub. information comes directly from the person giving the history. Objective information comes from the provider or medical staff and includes factual information such as vital signs, PE, lab and imagery results.
What consists of subjective information? (3)
Chief complaint, HPI, and ROS
What is the History of Present Illness (HPI)?
The story of symptoms and events that led to the clinic visit and summarizes the reason for the visit. The HPI is a vital component of the chart as it is the basis for the entire workup that follows.
What is the Review of Systems (ROS)?
A head-to-toe overview of the patient’s body-ssytems phrased in the form of POSITIVES and NEGATIVES. It includes symptoms that not relevant to the chief complaint. it does NOT contain context.
Reminder (No Answer)
The ENTIRE emergency department visit is BASED on the patient’s story.
Every subjective complaint is ALWAYS followed up with an objective evaluation somewhere else in the chart. One way to “check” your chart for completeness is to find the subjective complaints in the HPI and follow them through the rest of your chart.
No Answer
What are the elements of the HPI (8) ?
Onset, Timing, Location, Quality, Severity, MFs, Assoc Sx, Context
OTL QSMAAC
For the first three elements of the HPI, what do their descriptions consist of?
OTL
Onset - when did the complaint begin?
Timing - Has it been constant, intermittent, waxing and waning?
Location - Where is the discomfort?
For the last five elements of the HPI, what do their descriptions consist of?
QSMAAC
Quality - Does it feel sharp, dull, aching, cramping….?
Severity - How bad is it? Mild, Moderate, Severe or 0-10
MFs - What makes it better? What makes it worse?
Assoc Sx - Do any other symptoms accompany the complaint?
Context - Is there anything else thats important?
What are NOT elements of the HPI but are included because they are important information??
The Age/sex of the pt and their chief complaint! DUH!
For the ROS and Body Systems
Where would fever, weight loss, sweats be annotated in the systems?
Constitutional
For the ROS and Body Systems
Where would change in vision, eye pain, double vision be documented?
Eyes
For the ROS and Body Systems
Where would earache, nosebleed, congestion, sore throat be documented?
Ear/Nose/Throat (ENT)
For the ROS and Body Systems
Where would chest pain, palpitations, leg swelling be documented?
Where would SOB, cough, sputum, wheezing be documented?
Where would abd pain, N/V/D, black and bloody stools be documented?
Where would dysuria, frequency, urgency, hematuria be documented?
Where would joint pain and muscle pain be documented?
Where would rash, itching, abrasion, laceration be documented?
Cardiovascular
Respiratory
Gastrointestinal
Gentiourinary
Musculoskeletal
Integumentary/Skin
T/F HPI is not all inclusive but ROS is.
True. HPI only includes information about the chief complaint. ROS, however, will include all information about all positive and negatives.
