OP 3: Subjective

Question 1

Subjective

Answer 1

Includes:
- Chief complaint (CC)
- HPI
- ROS

Question 2

HPI

Answer 2

History of Present Illness
- Story of symptoms & events that led to clinic visit
- Summarizes reason for visit

Question 3

Elements of HPI:

Answer 3

1. Onset
2. Timing
3. Location
4. Quality
5. Severity
6. Modifying Factors
7. Associated Sx
8. Context

Question 4

Single Complaint Formula

Answer 4

Best for: patients with only 1-2 complaints that have not been previously evaluated
Includes:
- Age & sex
- Complaint & onset
- Positive associated Sx
- Pertinent negatives
- Other important context

Question 5

Multiple Complaint Formula

Answer 5

Best for patients with:
- Multiple complaints
- Routine follow-up for chronic illness
- Different treatment plans for different complaints

Question 6

Chronologic Formula

Answer 6

Best for patients:
- who have multiple comorbidities
- who have had significant work-up or eval
- who are established with follow-up for chronic illness

Includes:
1. Age & sex
2. Relevant PMHx
3. Previous evaluation(s)
4. Previous treatments
5. Summary of current complaints
6. Elements of complaint 1
7. Elements of complaint 2
8. Context

Question 7

ROS

Answer 7

Review of Systems
- Head to toe overview of the patients body systems, using positives and negatives

Question 8

Organization of ROS

Answer 8

1. Constitutional
2. Eyes
3. Ear/Nose/Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integumentary/Skin
10. Neurological
11. Psychiatric
12. Endocrine
13. Hemalogic/Lymph
14. Immunologic