Scribe Training #3 - Hpi

Front 1

What is HPI?

Back 1

History of Present Illness = story of symptoms and events leading to the patient's ED visit; summarizes the reason for the visit.

Front 2

What kind of information belongs in the HPI.

Back 2

Subjective

Front 3

HPI records what?

Back 3

Subjective complaints that give rise to the entire patient workup.

Front 4

HPI should only include what?

Back 4

-- The Chief Complaint and Important Context

Front 5

For HPIs, the patient is the what? For pediatric patients what should you do?

Back 5

Historian; Document who is providing the information e.g. "Per the mother"

Front 6

What do you do when a complete history is not available?

Back 6

Document why it's not. And specifically how you know it.
e.g. "HPI is limited due to patient's non-verbal status" or "AMS"

Front 7

A complete HPI contains what elements

Back 7

Onset, Timing, Location, Quality, Severity, Modifying factors, Associated Symptoms, Context

Front 8

Explain the HPI elements:
Onset, Timing, Location, quality, Severity, Modifying factors, Context

Back 8

onset - when did the complaint begin?
timing - has it been constant, intermittent, or waxing and waning?
Location - Where is the discomfort?
Quality - Does it feel sharp, dull, aching, cramping?
Severity - How bad is it?
Mod factors - what makes it better? What makes it worse?
Assoc symptoms - Do any other symptoms accompany the complaint?
Context - Is there anything else that's important?

Front 9

Writing an HPI includes what 6 things.

Back 9

1. Age and sex of pt
2. State complaint and onset
3. Describe quality, location, and timing
4. Has anything improved or worsened it?
5. List assoc. symptoms
6. List pertinent negatives.

Front 10

What does the HPI focus on?

Back 10

The moment a pt realized they needed to go to the ER; inc context, events, and symptoms.

Front 11

HPI vs. ROS

Back 11

HPI = info directly relevant to the chief complaint; summarizes the context and events leading to ER visit
ROS = contains all patient complaints, both from HPI and otherwise.

Front 12

What is the ROS?

Back 12

Head-to-toe overview of the pt's body systems.

Front 13

ROS is phrased in the form of?

Back 13

Positives and Negatives

Front 14

ROS is a complete list of ?

Back 14

All the patient's complaints.

Front 15

ROS includes ?

Back 15

symptoms already placed in the HPI; symptoms not relevant to the chief complaint

Front 16

It is very impt that the listed ROS symptoms do not ....?

Back 16

Contradict any of the symptoms discussed in the HPI.

Front 17

To communicate that the pt did not mention any complaints other than those documented, document what?

Back 17

"All other systems negative except as marked"

Front 18

When a complete history is not available, it is impt to document what?

Back 18

Complete ROS unobtainable due to pt's condition.

Front 19

ROS' 14 Body systems

Back 19

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. Hematologic/Lymph
14. Immunologic

Front 20

Examples of Constitutional

Back 20

Fever, Weight loss, Sweats

Front 21

Eyes

Back 21

Change in vision, Eye pain, double vision

Front 22

Ear/Nose/Throat

Back 22

Ear ache, Nose bleed, Congestion, Sore throat

Front 23

Cardiovascular

Back 23

Chest pain, Palpitations, Leg swelling

Front 24

Respiratory

Back 24

SOB, Cough, Sputum, Wheezing

Front 25

Gastrointestinal

Back 25

Abdominal pain, N/V/D, Black or Bloody stools

Front 26

Genitourinary

Back 26

Dysuria, Frequency, Urgency, Hematuria

Front 27

Musculoskeletal

Back 27

Joint pain, Muscle pain

Front 28

Integumentary/Skin

Back 28

Rash, itching, Abrasion, Laceration

Front 29

Neurological

Back 29

Headache, Syncope, Seizure, Numbness, Focal weakness

Front 30

Psychiatric

Back 30

Depression, Anxiety

Front 31

Endocrine

Back 31

Polyuria, polydipsia

Front 32

Hematologic/Lymph

Back 32

Bleeding gums, easy bruising, swollen lymph nodes

Front 33

Immunologic

Back 33

HIV/AIDS, Splenectomy

Front 34

Common PMHx: General

Back 34

HTN, Hyperlipidemia/Dyslipidemia, CA, DM

Front 35

Common PMHx: Cardiac

Back 35

MI, CAD, Angina, CHF, AFIB

Front 36

Common PMHx: Pulmonary

Back 36

PE, PNA, COPD, Asthma

Front 37

Common PMHx: Abdominal

Back 37

GERD, AAA, Pancreatitis, Hepatitis, Diverticulitis

Front 38

Common PMHx: GU

Back 38

Kidney stones, UTI, Renal insufficiency/failure

Front 39

Common PMHx: Psych

Back 39

CVA, TIA, Epilepsy/Sz, Migraines, Dementia, Alzheimer's

Front 40

Common PMHx:Psych

Back 40

Depression, Anxiety, Bipolar, Schizophrenia

Front 41

Common PMHx: Other

Back 41

DVT, MRSA, RA (Rheumotoid Arthritis), CBP (Chronic Back Pain)

Front 42

Common PSHx: ENT

Back 42

Tonsillectomy, Adenoidectomy, Myringotomy

Front 43

Common PSHx: Cardiac

Back 43

CABG, Coronary Stents, Pacemaker, AICD, Catherterization, Angioplasy, Valve replacement

Front 44

Common PSHx: Abdominal

Back 44

Appendectomy, Cholecystectomy, Herniorrhaphy, Gastric Bypass, Colectomy, Colostomy

Front 45

Common PSHx: GU

Back 45

Hysterectomy, C-section, Oophorectomy, Salpingo-oophorectomy, Tubal ligation, TURP

Front 46

Common PSHx: Ortho

Back 46

AKA/BKA, Hip Arthroplasty

Front 47

Common PSHx: Neuro

Back 47

Carotid Endarterectomy, Craniotomy, AV Shunt

Front 48

Common PSHx: Other

Back 48

Ex Lap, Mastectomy, PICC line

Front 49

G: P: A:

Back 49

G - # of times the patient has been pregnant // P - # of lives births that pt has had // A - # of total abortions (miscarriages or elective)

Front 50

General/Constitutional: Normal & Abnormal

Back 50

Normal = NAD
Abnormal = Mild/Moderate/Severe Distress
Cachectic/Emaciated/Malnourished
Somnolent