Class 3

Question 1

What is the first information a physician discuses with a patient?

Answer 1

their subjective information

Chief complaint, HPI, ROS

Question 2

Should a chief complaint be included in the HPI?

Answer 2

Yes, always

Question 3

What do you need to make sure the chief-complaint is for billing reasons?

Answer 3

something specific

Question 4

Fix “check-up” for billing

Answer 4

…. management visit

Question 5

Fix “follow-up” for billing

Answer 5

… management evaluation

Question 6

Fix “lab results” for billing

Answer 6

Discuss treatment plans for …

Question 7

Fix “medication refill” for billing

Answer 7

Evaluation of medical management of …

Question 8

How is the ROS phrased?

Answer 8

In terms of positives and negatives

The ROS does not include context

Question 9

What are the eight elements of the HPI?

Answer 9

Onset, timing, location, quality, severity, modifying factors (positive and negative), associated Sx, context

Question 10

Is the Chief Complaint an element of the HPI?

Answer 10

Not technically an element but needs to be included

Question 11

What should always be the beginning of the HPI?

Answer 11

the age/sex of the patient and chief complaint

Question 12

What form should the HPI be in?

Answer 12

complete sentences

Question 13

What is always relevant in the HPI?

Answer 13

answers to EVERY question the doctor asks

Question 14

If patient says “It started Monday”

Answer 14

Symptoms began 3 days ago

Question 15

If patient says “It got better”

Answer 15

Sx improved

Question 16

If patient says “I took Tums and it didn’t help”

Answer 16

Sx were unchanged by Tums

Question 17

If patient says “I have lower back pain, but I always have that”

Answer 17

Patient has chronic lower back pain, unchanged from baseline

Question 18

If patient says “It hurts when I touch it”

Answer 18

Pains are worsened by palpation of the area

Question 19

If patient says “Nothing makes it better or worse”

Answer 19

There are no modifying factors

Question 20

If patient says “My sister has the same cold”

Answer 20

Positive sick contact with sister who has similar symptoms

Question 21

If patient says “I throw up when I eat or drink anything”

Answer 21

The vomiting is exacerbated by PO intake

Question 22

If patient says “It feels like a fizzing soda in my chest”

Answer 22

Chest pain is described as “fizzing soda” sensation

Question 23

If patient says “I have the flu”

Answer 23

Pt has rhinorrhea and cough (do not document self diagnoses)

Question 24

What is the most commonly used HPI structure”

Answer 24

the single complaint formula

Question 25

When do you use the single complaint formula?

Answer 25

best for patients with only 1-2 complains that have not been previously evaluated

Question 26

What is the structure of the single complaint formula?

Answer 26

1) age and sex 2) complaint and onset 3) quality, severity and location 4) modifying factors 5) positive associated Sx 6) pertinent negatives 7) other important context

Question 27

Give an example of a standard HPI

Answer 27

43 y/o female c/o HA since 2 days ago. Pt describes a constant mild pressure behind the eyes. Pain is worse w/ bright light and unchanged by Advil. The pt also has associated nausea, but denies fever or weakness. Pt has had similar HAs in past.

Question 28

When do you use the multiple complaint formula?

Answer 28

Patients who have multiple complaints, routine follow-up for chronic illnesses, different treatment plans for different complaints

Question 29

Multiple complaint formula

Answer 29

Each complaint or disease is documented in a separate paragraph

Question 30

When do you use the chronological formula for HPI?

Answer 30

best for complex stories patients with multiple comorbidities, patient who have had a significant workup or evaluation in the past, established patients here for follow-up of a chronic illness

Question 31

What is different about the chronological formula for the HPI?

Answer 31

You start with a chronological recap of relevant PMHx, previous evaluations and treatments Then you move into complaints, elements, and context like a normal HPI

Question 32

Example of how to start the chronological formula

Answer 32

86 y/o male with PMHx of COPD, HTN and HLD returns today.

Question 33

Should the ROS and the HPI ever contradict each other?

Answer 33

No, since they are both subjective Information that is found in the HPI and extra irrelevant information to chief complaint should be put in the ROS

Question 34

Do you need to answer every check box of the ROS?

Answer 34

No, only use the boxes that the doctor specifically asks about

Question 35

How is the ROS organized?

Answer 35

by body systems

Question 36

Scribe attestation

Answer 36

Documented by Kate Appel acting as a scribe for Dr. X. Date/time

Question 37

Constitutional body system in ROS

Answer 37

Fever, weight loss, sweats

Question 38

Endocrine body systems in ROS

Answer 38

polyuria, polydipsia

Question 39

Genitourinary body system in ROS

Answer 39

Dysuria, frequency, urgency, hematuria

Question 40

How do you say "patient complains of" ?

Answer 40

Pt c/o

Question 41

What is the abbreviation for headache?

Answer 41

HA

Question 42

What is the abbreviation for "symptoms" ?

Answer 42

Sx

Question 43

What is the abbreviation for "diagnosed" ?

Answer 43

Dx

Question 44

What is the medical term for runny nose?

Answer 44

Rhinorrhea

Question 45

What is the medical term for tingling?

Answer 45

Paresthesia

Question 46

What is the medical term for muscle pain?

Answer 46

Myalgia

Question 47

What does "onset" mean?

Answer 47

when the problem began

Question 48

What does "timing" mean?

Answer 48

How often does the patient have their symptoms Constant, intermittent, waxing and waningq

Question 49

Difference between intermittent and waxing/waning

Answer 49

Intermittent: symptom comes and goes Waxing/waning: symptom is always there but the intensity fluctuates

Question 50

What does "quality" mean?

Answer 50

What does the symptom feel like? Is it aching? Burning? Etc/

Question 51

Should pertinent negatives go in the HPI?

Answer 51

yes!