OP Course 1: CC/HPI/ROS - Subjective Flashcards
What are the three components of the subjective portion of SOAP notes?
Chief complaint (CC)
History of present illness (HPI)
Review of systems (ROS)
What is the function of HPI?
Story of symptoms and events leading to clinic visit; builds off the chief complaint
What is the function of the ROS?
Head-to-toe checklist of the entire body (+, -, or not addressed); not limited to HPI
What is the function of the CC? Why is it required?
Primary reason that brought the patient to the clinic
- legally required
- required for billing
What is a way to rephrase “check-up” to make it a reimbursable term in the CC?
3 month diabetes management
What is a way to rephrase “follow-up” to make it a reimbursable term in the CC?
HTN management evaluation
What is a way to rephrase “lab results” to make it a reimbursable term in the CC?
Discuss treatment options for elevated TSH
What is a way to rephrase “medication refill” to make it a reimbursable term in the CC?
Evaluation of medication management for HTN
What is a way to rephrase “annual check-up” to make it a reimbursable term in the CC?
Wellness exam
What are the 8 elements of the HPI?
- Onset
- Timing
- Location
- Quality
- Severity
- Modifying factors
- Associated symptoms & pertinent negatives
- Context
What does “onset” refer to in the HPI?
When symptoms began
What does “timing” refer to in the HPI?
Constant? Intermittent? Waxing & waning?
What does “location” refer to in the HPI?
Where pain or complaint is located
What does “quality” refer to in the HPI?
Sharp? Dull? Throbbing? Burning?
What does “severity” refer to in the HPI?
Mild? Moderate? Severe? 1-10?
What does “modifying factors” refer to in the HPI?
Do certain things make it better or worse? What have they tried?
What are “associated symptoms” and “pertinent negatives”?
Associated symptoms: symptoms that accompany the chief complaint?
Pertinent negatives: Important symptoms that are not present (ex: CC of chest pain, negative for SOB)
What does “context” refer to in the HPI?
Any other information (ex: testing, previous Dx, etc.)
What is a good formula to follow for a single complaint HPI? (6)
- Age & sex
- Complaint & onset
- Quality, timing, & location
- Modifying factors
- Associated symptoms & pertinent negatives
- Context
How should you set up a chronologic formula HPI for multiple chief complaints?
Age/sex –> relevant PMHx –> Previous evaluation –> Previous treatment –> Current CC(s) –> Element of CC1 –> Element of CC2…3…4 –> Context
What is an example of a good intro phrase to start a HPI?
Pt is a 36 y/o male…last seen…
What is a physician-led ROS?
ROS is filled out by scribe in the room with physician and patient
What is a nurse-led ROS?
Nurse performs ROS on their own; should still be checked for errors by scribe
What is a ROS statement?
Short sentence that refers the ROS to the HPI (rare); should make HPI more detailed
Ex: “ROS per HPI, otherwise negative”
