ED 3 Flashcards
Subjective Information
Comes directly from the person giving the history.
Consists of CC, HPI, and ROS
Objective Information
Comes from the provider or medical staff and includes factual information, such as vital signs, physical exam, laboratory and imaging results.
History of Present Illness (HPI)
Written in complete sentances and is the paitents story.
Review of Systems (ROS)
Incomplete sentances and phrased in the form of positives/negatives.
HPI Elements
Onset, Timing, Location, Quality, Severity, Modifying Factors, Associated Sx., Context
When did the complaint begin?
Has it been constant, intermediate, or waxing and aining?
HPI Context
Risk factors related to the complaint.
If paitent has had similar symptoms in the past - when and is there a diagnosis in the past.
If the paitent has had any prior testing related to their complaint.
Medical histories, surgeries, or social habits that are relevant
HPI Structure
- First sentence - age, sex, CC, and onset.
2 . Timing, quality, location, - Modifying factors,
- Associated sx., pertinent negatives
- Context
HPI Phrasing
Be specific in documentation, and if unsure of medical documentation, then quote the patient.
DO NOT include self diagnosis
ROS Structure
Constitutional, Eyes, Ear/Nose?Throat, Cardiovascular, Gastrointestinal, Musculoskeletal, Integumentary/Skin, Neurological, Psychiatric, Endocrine, Hematologic/Lymph, Immunologic
ROS Tips
Goes very fast so pay attention.
Only document symptoms doctor asks.
Complete in less than 1 minute.
When unable to be obtained document that.
External documents reviewed…
Document provider review of history
May also contain
History obtained from independent historian
Document if history from an independant historian
May also contain relationship between paitent and historian, and reason a confirmation is judged to be nessecary.
Documnet chronic illnessess and risk
