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Terms in this set (171)
What is an HPI?
the story of symptoms and events that led to the patient's ED visit. (subjective)
Where is the HPI located?
Beginning of every chart summarizing the reason for the visit.
What should the HPI include?
information directly related to the chief complaint and important context for that patient.
All other information belongs in a different section of the chart.
Who is the historian?
Usually the patient.
Pediatric patients or patients incapable of speaking, always remember to document who is providing the information.
What should you document when the complete history is not available?
Document why the history is limited. For example,
"HPI is unobtainable due to the patient's non-verbal status."
Write only what you know about the patient, specifically how you know it. Do not assume anything.
What does the HPI determine?
The entire visit to the ED. It is based on the patient's story.
What does every subjective complaint followed up with?
An objective evaluation somewhere else in the chart; the PE or Results section
One way to check up on the completion of your chart is to find the subjective complaints in the HPI and find the correlating objective evaluation.
How many elements should a complete HPI contain?
4 elements + Chief complaint
When did the complaint begin?
Has it been constant, intermittent, or waxing and waning?
Where is the discomfort?
Does it feel sharp, dull, aching, cramping, etc?
How bad is it? Mild, moderate, severe? or 0-10?
what makes it better? what makes it worse?
Do any other symptoms accompany the complaint?
Is there anything else that's important?
Formula for Writing a Basic HPI
1. Begin with the age and sex of patient.
2. State the complaint and onset.
3. Describe the timing, quality, severity, and location.
4. Has anything improved or worsened it?
5. List associated symptoms.
6. List pertinent negatives
7. Describe any other important context specific to that patient.
Formula for writing a detailed HPI
1: Complaint + Onset
2: Quality, Severity, Location, Radiation
3: Associated Symptoms, Pertinent negatives
4: modifying factors
-initiating factor that brought patient to the ED?
T/F: the more closely you can stick to the formula, the better your HPI will be?
T/F: Remember the patient's answers and focus on remembering the individual facts.
F. remember the patient's answers as a general story.
T/F: Group all related information together; finish describing all the details of one complaint before moving on to the next.
T/F: Try to word your HPI as a doctor would speak.
T: Translate things that the patient says into phrasing that sounds more like a doctor. WHen in doubt, you may always document direct patient quotes.
"I took tums and it didn't help"
The symptoms were unchanged by Tums
"I have low back pain, but I always have that"
He notes chronic back pain. Unchanged from baseline
It hurts when I touch it
The symptoms are worsened by palpation of the area
"Nothing makes it better or worse"
the symptoms are unchanged by any position or activity
my sister has the same cold
positive sick contact with sister who has similar symptoms
if i try to eat or drink anything, i throw it back up
the vomiting is exacerbated by PO intake
it feels like a fizzing soda in the middle of my chest
he describe the symptoms as "a fizzing soda" in his central chest.
Do not use days of the week for onset
count the number of days since the symptoms started, or write a date
do not use the word "got"
use phrasing like "the symptoms became worse" or "the symptoms worsened"
do not start every sentence the same
Vary the beginning of your sentences and avoid repetition, Simply drop the "pt states" and start your sentence from the next word.
Do not document self diagnoses in the HPI
describe the specific symptoms affecting the patient.
for example: patient notes a runny nose and vomiting
Do not include PMHx, PSHx, or SHx that is not relevant to the chief complaint
document only medical histories, surgeries, or social habits that directly relate to the patient's chief complaint
What should you document for patients seeking evaluation for a symptom that they have experienced at some time in the past?
-anything new or different about their symptoms today
-how long ago the similar symptoms occurred
-if they sought professional treatment at that time
-any result or diagnosis from previous evaluations
If the patient has experienced similar symptoms in the past...
it is very likely that their current symptoms are related
It is less likely that their current symptoms are life threatening...
if they have survived the same symptoms in the past
What should you document if the patient has been evaluated by another healthcare provider for a similar complaint?
- What symptoms prompted the prior evaluation?
- How long ago did the prior evaluation occur?
- Who did they see? (Name and specialty)
- What treatment did they receive? Did it help?
- What diagnosis was given?
What should you document if the patient has had any prior testing or study related to their complaint?
Specific name of the test (lab, XR, CT, MRI)
T/F: every question the doctor asks important
What is your goal when the doctor asks a question?
capture the answer.
The patient's entire ED visit is based on their answers to questions
what should you ALWAYS write in an HPI?
the answers to the doctor's specific questions
What do the doctor's questions do?
Help raise or lower his suspicion for a particular disease. This helps him decide which tests to order.
What happens if your chat is missing an answer to a question?
There is no record the doctor ever asked it.
T/F: the HPI drives the rest of the visit
How should you order your HPI?
When should you listen closely?
Listen closely for the reasoning that finally made the patient choose to come to the ED
Guidelines for HPI phrasing
1. Write in complete sentences
2. Focus on capturing the initiating facot that brought the patient to the ED
3. USe proper capitalization and punctuation
4. Always check for spelling
5. Only use approved medical abbreviations. Google before using. When in doubt, write it out!
What is the key to writing a trauma HPI?
Focusing on the exact mechanism of injury (MOI)
Describe every possible detail about the circumstances and events causing the injury.
What are the 4 most important symptoms to document for any trauma patient?
2. Head Injury
3. Neck Pain
4. Back pain
Trauma HPI template?
1. complaint and onset
2. what caused the incident
-how did they land?
-what did they land on?
3. what injuries did they sustain
-location ,quality, severity, radiation
4. modifying factors
5. associated symptoms, pertinent negatives
-loc, head injury, neck or back, numbness,
-similar symptoms? previous injuries? initiating
factor that brought them to ED?
What does the doctor ask when patient is involved in a MVA?
1. Where you the driver or passenger?
2. Were you wearing a seatbelt?
3. How fast were you moving?
4. What part of the car was hit?
5. Did it hit a stationary object or another vehicle?
6. Did the airbags deploy?
7. Did you lose consciousness?
8. Did you hit your head?
9. Did you sustain any injuries?
10. How much damage was done to your vehicle?
11. is the car drivable?
12. were you able to get out of the vehicle? (self-
13. Were you able to ambulate (walk) on scene?
14. Did you require EMS treatment on scene?
What is the HPI?
contains information that is directly relevant to the chief complant.
Summarizes the story, context and chronology that led to the patient's ER visit.
What is the ROS?
Head to toe checklist of symptoms the patient does or does not have
How is the ROS phrased?
simple list of positives and negatives
What does the ROS contain?
all symptoms the patient mentioned in the HPI.
T/F: No story or context is placed in the ROS
What should the ROS never do?
ROS should never contradict the HPI - since they are both subjective.
What does "all other systems negative except as marked?
to communicate that the patient did not have any complaints other than those documented.
Some physicians may not ask you to document this.
What should you document if the ROS is limited?
State that the HPI and ROS is limited.
"A complete ROS is unobtainable due to the patient's condition."
What should you not do in the ROS for major symptoms?
Never just mention "positive chest pain" or "positive shortness of breath" in the ROS without providing further explanation in the HPI.
How many elements should a complete ROS have?
or 2 + all other systems negative except as marked included
Fever, weight loss, sweats
change in vision, eye pain, double vision (diplopia)
ear ache, nose bleed, congestion, sore throat
chest pain, palpitations leg swelling
sob, cough, sputum, wheezing
abdominal pain, v/n/d, black or bloody stools
dysuria, frequency, urgency, hematuria
join pain, muscle pain
rash, itching, abrasion, laceration
headache, syncope, seizure, numbness, focal weakness
polyuria, polydipsia (excessive thirst)
bleeding gums, easy ruising, swollen lymph nodes
Example of ROS
constitutional: negative for sweating
cardiovascular: positive CP. Negative for leg swelling
pulmonary: positive SOB
GI: positive nausea. Negative vomiting.
"all other systems negative except as marked"
worse with physical exertion
worse with deep breaths
radiation to the back
mi, pe, ptx
diaphoresis, nausea, vomiting
dvt causing pe
mi risk factors
cad, htn, hld, dm, smoking, fhx < 55 y/o
pe risk factors
hx dvt/pe, known dvt, recent surgery, immobilization, a-fib, cancer, pregnancy/birth control
bilateral leg swelling
unilateral leg swelling
DVT causing PE
hx of tobacco abuse
mi, pe, pna
appendicitis, cholecystitis, diverticulitis
blood in vomit or stool
gi bleed, abdominal aortic aneurysm (AAA)
diarrhea risk factors
recent foreign travel, recent camping, bad food exposure, sick contacts, recent antibiotics, recent hospitalization
----------FEMALE LOWER ABDOMINAL PAIN------
fever, rlq pain
------------LOW BACK PAIN-------------
low back pain
weakness/numbness in lower extremities
spinal cord injury
numbness of the groin
spinal cord injury or cauda equina
loss of bowel or bladder control
spinal cord injury or cauda equina
history of IVDA
changes in speech or vision
CVA, Subarachnoid Hemorrhage (SAH)
difficulty with balance
meningitis, cva, sah
worse headache of life/ thunderclap onset
hemorrhagic cva, sah
syncope or seizure
cva risk factors
htn, hld, dm, smoking, fhx cva, hx tia/cva, afib
tongue bite wound
changes in speech or vision
changes in speech/vision
hx of depression or drug abuse
hx of diabetes
hemorrhagic cva, subdural hematoma
Hemorrhagic CVA, Subdural Hematoma
spinal cord injury
spinal cord injury
sob or chest pain
ptx, cardiac contusion
splenic or liver laceration
htn, hld, ca, dm
mi, cad, angina, chf, afib
pe, pna, copd, asthma
gerd, aaa, pancreatitis, hepatitis, diverticulitis
kidney stones, uti, renal insufficiency/failure
cva, tia, epilepsy/seizure, migraines, dementia, alzheimer's
depression, anxiety, bipolar, schizophrenia
dvt, mrsa, RA (rheumatoid arthritis), CBP (chronic back pain)
tonsillectomy, adenoidectomy, PE tubes
cabg, coronary stents, pacemaker, aicd, catheterization, angioplasty, valve replacement
appendectomy, cholecystectomy, herniorrhaphy, gastric bypass, colectomy, colostomy, nephrectomy
oophorectomy, salpingo-oophorectomy, tubal ligation
AKA/BKA, arthroplasty, spinal fusion
cardotid endarterectomy, craniotomy, VP shunt
mastectomy, PICC line
what does subjective mean?
based on the patient's feelings
based on the physician's finding (factual information)
comes and goes
waxing and waning
always present but changing in intensity
something that makes a symptom better or worse
to make worse