Writing An HPI Flashcards
What are the elements of a complete HPI?
Onset Timing Location Quality Severity Modifying factors Associated SX Context
How many elements makes a complete HPI?
4
What is the HPI writing formula?
1) age & sex
2) CC and onset
3) describe quality, location, timing
4) has anything improved or worsened it?
5) associated SX
6) pertinent neg.
7) context
How do you reword “it didn’t help…”
Sx were unchanged by…
How do you reword “I always have x…”
Pt notes chronic X, unchanged from Baseline.
How do you reword “it hurts when I touch it…”
Sx are worsened by Palpation of area…
How do you reword “nothing makes it better or worse”?
Sx are unchanged by any position or activity
How do you reword “family member x has same cold”?
Positive sick contact with family member X who has similar Sx.
How do you reword “if I try to eat or drink anything I throw it back up”
Vomiting is exacerbated by PO intake
How do you reword “it feels like a fizzing soda in the middle of my chest”
Pt describes Sx as “a fizzing soda” in his central chest
What should you record when a patient says they have or have not experienced certain Sx?
Pt notes x but denies y
Why is it so important to document previous similar Sx?
Because it is very likely their current Sx are related and allows for a quicker Dx. Should always doc:
- Anything new or diff
- How long ago
- If they sought professional tx
- Previous Dx
What are the 4 most important Sx do document in a trauma HPI?
Loc
Head injury
Neck pain
Back pain
And MOI
What is the difference between an HPI and ROS?
HPI is a story and context of all things related to the cc. ROS is a head to toe checklist of Sx the PT has or does not have
How many elements makes a complete ROS?
10
What are all the body Systems listed in the ROS?
Constitutional Eyes ENT Cardiovascular Respiratory GI GU MS integumentary Neuro Psych Endocrine Hematologic/lymph Immunologic
If you mark “all other systems negative except as marked” how many elements makes a complete ROS?
2
What does G in GPA represent?
Gravida: total number of times pregnant
What does the p in GPA stand for?
Para: total number of live births with viable children the PT has had
What does the a in GPA stand for
Abortion: total number of elective abortions or miscarriages
