HPI Elements Flashcards
Location
place on the patient’s body where the patient is experiencing signs and symptoms. The location does NOT mean the place where the patient was when the injury occurred, but the anatomical geographic description.
Timing
when the pt experiences the signs and Sx. Try to document the time for the Sx onset. Note: timing is when the signs and Sx occur; Duration is HOW long they last. If a pt complains of nausea and vomiting onset at approximately 9 am and lasted all morning “onset at 0900” is the timing and “continuous throughout the morning” is the duration
Duration
the length of time the pt’s signs and Sx exist. If the pt states they have had intermittent CP for the pst two hours, “the past two hours” denotes the duration. Also, if the pt states that their episodes of CP last approximately two minutes each, then that counts as duration.
Severity
describes how bad the patient’s problem is. Severity may be rated on a pain scale of 1 to 10 with “7” written as “7/10”. This can also include phrases such as “more severe” or “less severe” etc.
Quality
distinguishes the characteristics of the CC or sign or Sx, and is usually an adjective. Ex. “throbbing headache” where “throbbing” indicates the severity. Others include: shooting, pounding, crushing, and/or stabbing.
Modifying Factors
are the things the pt has done to alleviate the signs or Sx or the things that make the Sx better or worse. Ex. chest pain sometimes gets worse with exertion and improves with rest. May also include treatment prior to arrival, such as “pt took tylenol for fever with relief” or “pt took NTG x3 w/o relief”
Context
describes what the pt was doing when he or she experienced signs and Sx. If the pt cuts her hand while sharpening a knife, then sharpening the knife is the context. Ex. “occurred at work” or “while sitting down”
Associated Signs and Symptoms
any problems in addition to the chief complaint that the pt complains of or denies. If the pt complains of CP with some shortness of breath and nausea, chest pain is the CC and shortness of breath and nausea are associated signs and symptoms
