ED Scribe Class 3 - History of Present Illness (HPI) Information

What are the HPI Elements

Chief Complaint, Onset, Timing, Location, Quality, Severity, Modifying Factors, Associated Sx, Context

if the patient says it got better, what should the scribe write

symptoms improved

If the patient says it hurts when I touch it, what should the scribe write

pain is worsened by palpatation of the area

if patient says I throw up when I eat or drink anything, scribe writes

The vomitting is exacerbated by PO intake

ROS

Body Systems

examples of Constitutional

Fever, weight loss, sweats

examples of eyes

changes in vision, Eye pain, double vision

examples of ENT

Earache, nosebleed, congestion, sore throat

Examples of cardiovascular

Chest pain, palpitations, leg swelling

examples of respiratory

SOB, Cough, Sputum, wheezing

If a completed ROS is unable to be obtained, scribe should document

A complete ROS is unobtainable due to patient’s condition