HPI Flashcards
Chief Complaint
Tells the reader why the patient wants to see the physician today
EX: New symptoms/conditions, following up on old symptoms/conditions, annual health exams, etc
Patient Identification
Identifies key information that introduces the patient to the reader
EX: Age, gender, and any pertinent PMHx
Onset
Tells when new symptoms started or when chronic symptoms began/changed
EX: This detail is important for ICD-10 coding, so as a scribe, you must make sure to record it
Timing
Describes how often and how predictably the symptom occurs
EX: Constant, Intermittent, waxing, waning
Current Status
Describes how the patient feels the symptom is doing right now compared to when it started
EX: Improving, worsening, stable, etc
Location
The exact site(s) of the symptom as specifically as the patient is able to describe
EX: Right ear, left lower abdomen, generalized, etc. This detail is very important for ICD-10 coding, so as a scribe you must make sure to record it
Quality
A description of what a symptom feels like to the patient
EX: Burning, itching, sharp, pressure, etc.
Severity
A description of how severe the patient feels the symptom is right now
EX: Mild, Moderate, severe
Quantity
Have the patient rank the symptom (usually pain) on a 0-10 scale
EX: Where 0 is the absence of symptoms, and 10 is extremely debilitiating symptoms
Modifying Factors
Describes anything the patient has tried that can make the symptom better or worse
EX: Back pain improved with the use of a heating pad but worsened when carrying groceries
Associated Symptoms
Other symptoms that either stemmed from the CC symptom or that the patient denied having
EX: CC of nausea may have associated symptoms of vomiting or epigastric pain, but denies diarrhea
Subtle Context
Take all the pieces you gathered above and combine them in a way that reads like a story of the patient’s symptoms.
EX: The goal is to tell the story enough that the other readers will understand it as if they were present for this encounter
