OP 3: Subjective (HPI/ROS)

S for Subjective (SOAP)

• _ information comes directly from the person giving the history.

→ In most cases, this is the patient.

→ Possibly a parent for pediatric patients.

→ Possibly a son/daughter for elderly patients.

• _ information is the first item the physician discusses with the patient upon entering the room.

• It is first section the scribe documents in the chart.

Subjective information includes:

• Chief complaint: main reason for the visit.

• HPI: The story of the chief complaint.

• ROS: A checklist of symptoms from all body systems.

What is the chief complaint?

The chief complaint if the primary reason (s) that brought the patient to the clinic.

ALWAYS include a chief complaint.

EVERY level of billing requires a chief complaint in order to be reimbursed for the service provided.

Chief Complaint - Billing

Some chief complaints are not reimbursable. “Follow-up” is the most commonly used non-reimbursable chief complaint, costing medical practices large sums of money each year.

Table that examples how to fix a non-reimbursable chief complaint:

Non-reimbursable: Reimbursable

• Check- up

• Follow-up

• Lab results

• Medication refill

Reimbursable

• 3-month diabetes management visit.

• HTN management evaluation

• Discuss treatment options for elevated TSH.

• Evaluation of medication management for HTN.

Examples of making this chief complaint billable: Results of bloodwork (low hemoglobin)

Visit to discuss treatment options for low hemoglobin.

History of Present Illness (HPI)

The story of symptoms and events that lead to the clinic visit. Summarizes the reason for the visit. The _ is a vital component of the chart as it is the basis for the entire workup that follows.

Review of Systems (ROS)

A head-to-toe overview of the patient’s body-systems phrased in the form of POSITIVES and NEGATIVES. It includes symptoms that are not relevant to the chief complaint. It does not contain context.

HPI Elements

A completed _ contains the following ELEMENTS:

Elements: Description

• 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? Mild, moderate, severe or 0-10.

• Modifying Factors: What makes it better? What makes it worse?

• Associated Sx: Do any other symptoms accompany the complaint?

• Context: Is there anything else that’s important?

Note: The chief complaint (CC) does not count as an element, the elements describe the CC.

Examples of HPI Context

• Risk factors related to the complaint (e.g. if the chief complaint is chest pain and they have hypertension).

• If patient had similar symptoms in the past when and if there a diagnosis is the past.

• If the patient has had any prior testing (and the results) related to their complaint (this may save us from repeating the same study).

• Medical histories, surgeries, or social habits that are relevant to the current evaluation.

HPI Writing Tips

• Always start with age/sex of the patient.

• Write in complete sentences.

• Use proper capitalization, punctuation, and grammar. Check your spelling.

• Only use approved medical abbreviations. When in doubt, write it out.

• Document the answer to EVERY question the doctor asks.

• Try to word your HPI as a doctor would speak.

• Do not document irrelevant information. (Typically, very little is irrelevant).

• Group all related information together.

• Finish describing all the details of one complaint before moving on to the next.

• Remember the general story, rather than focusing on remembering individual facts.

It is okay for scribes to misspell words because doctors do it all the time.

False

HPI Phrasing

Patient says…: Scribe Documents…

• It started monday: Symptoms began 3 days ago.

• It got better: Symptoms improved (avoid the word “got”)

• I took Tums and it didn’t help: The symptoms were unchanged by Tums.

• I have low back pain, but I always that: Patient has chronic lower back pain, unchanged from baseline.

• It hurts when I touch it: Pain is worsened by palpation of the area.

• Nothing makes it better or worse: There are no modifying factors.

• My sister has the same cold: Positive sick contact with sister who has similar symptoms.

• I throw up when I eat or drink anything: The vomiting is exacerbated by PO intake.

• It feels like a fizzing soda in my chest: Chest pain is described as a “fizzing soda” sensation.

• I have the flu: Pt has a runny nose and cough (do not document self-diagnoses).

If the patient says, “It hurts when I touch it,” what would you write in the HPI?

The patient’s pain is worse with palpation of the area.

HPI Structure

There are 3 primary methods of structuring an outpatient HPI.

• Single complaint Formula.

• Multiple Complaint Formula.

• Chronologic Formula.

The more closely you can stick to the formula, the better your HPI will be.

HPI Structure: Single Complaint Formula

• The “single complaint formula” is the most commonly used HPI structure and it is widely accepted across multiple specialties.

• This formula is best for patients with only 1-2 complaints that have not been previously evaluated.

Simple Complaint Formula

1. Age and Sex: 43-year-old female.

2. Complaint and Onset: Complains of headache since yesterday.

3. Quality, severity timing, location: Described as constant mild pressure behind the eyes.

4. Modifying Factors: The pain is worse with bright light and unchanged by Excedrin.

5. Positive Associated sx: The patient also has associated nausea.

6. Pertinent negatives: but denies fever, neck pain, weakness, or sick contacts.

7. Other important context: She has had similar HAs in the past but has not been diagnosed with migraines.

HPI Structure: Multiple Complaint Formula

• The “multiple complaint formula” structure is most commonly used in primary care, as PCPs typically discuss every complaint or disease in detail with the patient.

• It is effective for patients who have:

→ Multiple complaints

→ Routine follow-up for chronic illnesses

→ Different treatment plans for different complaints.

Multiple Complaint Formula - Example

Each complaint or disease is documented in a separate paragraph.

Ex: The pt made an appt. for a cough, but while here, the doctor also asks him about his HTN and HLD management, as well as his intermittent headaches that were present at his last visit.

→ Paragraph 1): Cough

→ Paragraph 2): HTN

→ Paragraph 3): HLD

→ Paragraph 4): HA

HPI Structure: Chronological Formula

The “chronologic” structure is best for complex stories:

• Patients with multiple comorbidities.

• Patients who have had a significant workup or evaluation in the past.

• Established patients here for follow-up of a chronic illness.

Chronologic Formula Steps

1. Age and Sex

2. Relevant PMHx

3. Previous Evaluation(s)

4. Previous Treatments

5. Summary of Current Complaints

6. Elements of Complaint 1

7. Elements of Complaint 2

8. Context

1-4: Chronological Recap - Makes this formula unique. Where you recap everything that has happened to the patient before today’s visit.

5-8: Then you continue the HPI like a normal single complaint or multiple complaint HPI.

Which HPI structure is best to use for a complex patient with multiple comorbidities and a recent work-up?

Chronological Structure (With recap)

What is the Review of Systems (ROS)

• The ROS is phrased as a simple list of positives and negatives.

• It includes all symptoms the patient mentions, even the ones already documented in the HPI.

• The ROS must never contradict the HPI since they are both subjective.

• Many EHRs have check boxes of symptoms to make the documentation easier. Only document the symptoms the doctor asks.

• The ROS is organized by body system.

ROS: Body Systems

System Name: Examples

• Constitutional: Fever, chills, weight loss, sweats

• Eyes: Change in vision, eye pain, double vision.

• Ear/nose/throat: Earache, nosebleed, congestion, sore throat, difficulty swallowing, postnasal drainage.

• Cardiovascular: Chest pain, palpitations, leg swelling.

• Respiratory: SOB, cough, sputum, wheezing.

• Gastrointestinal: Abdominal pain, N/V/D (Nausea, vomiting, diarrhea), black or bloody stools.

• Genitourinary: Dysuria, frequency, urgency, hematuria.

• Musculoskeletal: Joint pain, muscle pain.

• Integumentary/skin: rash, itching, abrasion, laceration.

• Neurological: headache, syncope, seizure, numbness, focal weakness.

• Psychiatric: depression, anxiety.

• Endocrine: Polyuria, polydipsia.

• Hematologic/Lymph: bleeding gums, easy bruising, swollen lymph nodes.

• Immunologic: HIV/AIDS

ROS Structures

The structure of the ROS varies from clinic to clinic, and so does the process of obtaining the ROS. Below are the four most common ways an ROS is obtained.

→ Physician led

→ Nurse led

→ Patient Questionnaire

→ Statements that refers to the HPI

“I don’t have any responsibility with regards to the ROS because the nurses complete the ROS at my facility.”

False

Scribe Attestation

• Though the chart is documented by the scribe, it is imperative to note that the provider reviewed and approved the documentation.

• We must therefore always include a scribe attestation on our charts. While the scribe is only responsible for the scribe attestation, always double check that your provider included theirs and their signature.