OP 3: Subjective Flashcards
Subjective
Information coming from then patient and the patients family/caregiver. Subjective information is the first item the physician discussed with the patient upon entering the room and the first section the scribe will document in the chart.
What are the three sections that are included in the subjective information section?
- Chief Complaint
- History of present illness (HPI)
- Review of Systems (ROS)
Chief Complaint
The primary reason that brought the patient to the clinic. ALWAYS include a chief complaint. EVERY level of billing requires a cheif complaint in order to be reimbursed for the service provided.
*Some chief complaints are not reimbursable (check-up, follow-up, lab results, medication refill)
History of Present Illness (HPI)
The story of symptoms and events that led to the clinic visits and summarizes the reason for the visit. The HPI is a vital component of the chart as it is the basis for the entire work up that follows.
Review of Systems (ROS)
A head-to-toe overview of the patient’s body-systems phrased in the form of POSITIVES and NEGATIVES. It includes symptoms that are not relevant to the chief complaint. It does NOT contain context.
What are the 8 HPI elements?
- Onset: When did it begin?
- Timing: What has the symptom itself been doing? Are symptoms constant, intermittent, waxing, waiting, etc?
- Location: Where is the discomfort?
- Quality: What does it feel like? Is the discomfort sharp, dull, aching, burning, pressure, etc?
- Severity: How bad is the pain? Mild, moderate, 0-10, etc?
- Modifying Factors: Does anything make the symptoms better or worse?
- Associated Sx: Do any other symptoms accompany the complaint? (i.e. nausea associated with abdominal pain)
- Context: Anything else that is important. We’re they around someone else that was sick?
What kind of information can provide HPI context
- Risk factors related to the complaint (i.e. if chief complaint is chest pain does patient have HTN)
- If patient had similar symptoms in the past and what treatment worked
- If the patient has had any prior testing related to their complaint
- Medical histories, surgeries, or social habits that are relevant to the current evaluation
HPI Writing Tips
- ALWAYS start with age/sex of patient
- Write in complete sentences (proper capitalization, punctuation, and grammar)
- CHECK YOUR SPELLING!
- ONLY use approved medical abbreviations! (When in doubt, write it out!)
- Document the answer to EVERY question the doctor asks
- Try to word your HPI as a doctor would speak
- Do not document irrelevant information (typically, very little it irrelevant)
- Group all related information together
- Finish describing all the details of one complaint before moving on to the next
- Remember the general story, rather than focusing on remembering individual facts.
HPI Phrasing
- Patient says: it started Monday > scribe documents: symptoms began 3 days ago
- Patient says: it got better > scribe documents: symptoms improved
- Patient says: I took tums and it didn’t help > scribe documents: symptoms were unchanged by tums
- Patient says: i always have that pain > scribe documents: patient had pain, unchanged from baseline
- Patient says: it hurts when I touch it > scribe documents: pains are worsened by palpitation
- Patient says: nothing makes it better/worse > scribe documents: no modifying factors
- Patient says: sister has the same cold > scribe documents: positive sick contact with sister
- Patient says: i throw up when i eat/drink > scribe documents: vomiting is exacerbated with PO intake
- Patient says: feels like a fizzing soda in my chest > scribe documents: chest pain is described as “fizzing soda” sensation
- DO NOT DOCUMENT SELF DIAGNOSIS (i.e. Patient says: i have the flu > scribe documents: patient has runny nose and cough)
Single Complaint HPI Formula
- Age and Sex
- Complaint and Onset
- Quality
- Modifying Factors
- Positive associated sx
- pertinent negatives
- other important context
Multiple Complaint HPI Formula
Each complaint goes in its own separate paragraph:
1. Intro
2. P1: Cough
3. P2: HTN
4. P3: HLD
5. P4: Headaches
Chronologic HPI Formula
Best for complex stories (patients with multiple comorbidities, significant work up or evaluation, or chronic illness patients:
1. Age and sex
2. Relevant PMx
3. Previous evals
4. Previous treatments
5. Summary of current complaints
6. Elements of complaint 1
7. Elements of complaint 2
8. Context
Body Systems
- Constitutional: fever, weight loss, sweats
- Eyes: change in vision, eye pain, double vision
- Ear/Nose/Throat: earache, nosebleed, congestion, sore throat, difficulty swallowing, post nasal drip
- Cardiovascular: chest pain, palpitations, leg swelling
- Respiratory: SOB, cough, sputum, wheezing
- Gastrointestinal: abdominal pain, N/V/D, black or bloody stools
- Genitourinary: dysuria, frequency, urgency, hematuria
- Musculoskeletal: joint pain, muscle pain
- Integumentary/Skin: rash, itching, abrasion, laceration
- Neurological: headache, syncope, seizure, numbness, focal weakness
- Psychiatric: depression, anxiety
- Endocrine: polyuria, polydipsia
- Hematologic/Lymph: bleeding gums, easy bruising, swollen lymph nodes
- Immunologic: HIV/AIDS
ROS Structures
- Physician Led: provider will question patient directly during evaluation
- Nurse Led: nurse will review systems with nurse in the room prior to the provider evaluation
- Patient Questionnaire: patient completed paperwork that will allow patient to describe their systems
- Statements that refers to the HPI: ROS per HPI was negative (usually for multiple complaint HPI)
Scribe Attestation
EVERY chart will need to be attested by scribe. It is a simple attestation statement:
“Documented by (scribe name) acting as a scribe for Dr. (provider name). (date/time)”
