ED 3

Question 1

Subjective Information

Answer 1

Comes directly from the person giving the history.
Consists of CC, HPI, and ROS

Question 2

Objective Information

Answer 2

Comes from the provider or medical staff and includes factual information, such as vital signs, physical exam, laboratory and imaging results.

Question 3

History of Present Illness (HPI)

Answer 3

Written in complete sentances and is the paitents story.

Question 4

Review of Systems (ROS)

Answer 4

Incomplete sentances and phrased in the form of positives/negatives.

Question 5

HPI Elements

Answer 5

Onset, Timing, Location, Quality, Severity, Modifying Factors, Associated Sx., Context

Question 6

When did the complaint begin?

Question 7

Has it been constant, intermediate, or waxing and aining?

Question 14

HPI Context

Answer 14

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

Question 15

HPI Structure

Answer 15

1. First sentence - age, sex, CC, and onset.
   2 . Timing, quality, location,
2. Modifying factors,
3. Associated sx., pertinent negatives
4. Context

Question 16

HPI Phrasing

Answer 16

Be specific in documentation, and if unsure of medical documentation, then quote the patient.
DO NOT include self diagnosis

Question 17

ROS Structure

Answer 17

Constitutional, Eyes, Ear/Nose?Throat, Cardiovascular, Gastrointestinal, Musculoskeletal, Integumentary/Skin, Neurological, Psychiatric, Endocrine, Hematologic/Lymph, Immunologic

Question 18

ROS Tips

Answer 18

Goes very fast so pay attention.
Only document symptoms doctor asks.
Complete in less than 1 minute.
When unable to be obtained document that.

Question 19

External documents reviewed…

Answer 19

Document provider review of history
May also contain

Question 20

History obtained from independent historian

Answer 20

Document if history from an independant historian
May also contain relationship between paitent and historian, and reason a confirmation is judged to be nessecary.

Question 21

Documnet chronic illnessess and risk