Powerpoint slides Flashcards
what is OPQRST
onset, palliative/provocative, quality, radiation/region, severity, timing
where is OPQRST
in the body of the HPI
how many OPQRST do you need in HPI
at least 4
end of HPI needs to have what
pertinent positives and negatives grouped together
if patient describes symptom you can do what
put it in quotations
if patient is LOC or AMS what do you put
history is very limited due to patient’s current condition
what is ROS
review of systems
ROS is important for what
billing and coding
how many ROS section is needed for billing
10
if patient is in MAS what to put for ROS
ROS not obtainable due to state of patient
what is some ROS sections
constitutional, HEENT, Eyes, cardio, respiratory, GI, GU, MSK
generic medications are written in
lower case
brand name medications are written as
first letter capitalized
social history consists of
smoking, alcohol, drug
during PEx focus on what
pertinent positives (exactly what they say), assume everything else is normal
