ScribeAmerica OP3: Subjective

subjective information comes from who?

patient

or historian (parent of patient if minor, caretaker of elderly patients)

what is the first item the physician discusses with the patient upon entering the room?

subjective information

3 components of subjective information

1) Chief complaint (CC)

2) History of present illness (HPI)

3) Review of symptoms (ROS)

chief complaint (CC)

main reason for patient visit

history of present illness (HPI)

the story of the chief complaint

review of symptoms (ROS)

checklist of symptoms from all body systems

every level of billing requires a __ in order to be reimbursed for the service provided

chief complaint

T/F: all chief complaints are reimbursable

F

what is the most commonly used non-reimbursible chief complaint?

follow-up

what are four examples of non-reimbursable chief complaints?

check-up

follow-up

lab results

medication refill

how would you fix a check-up to be reimbursible?

management visit of (insert condition)

how would you fix a follow-up to be reimbursible?

management evaluation of (insert condition)

how would you fix lab results to be reimbursible?

discuss treatment options for (insert condition)

how would you fix medication refill to be reimbursible?

evaluation of medication management for (insert condition)

why is the HPI a vital component of the chart?

it's the basis for the entire workup that follows

how are the body-systems phrased in an ROS

positives and negatives

does the ROS include symptoms that are not relevant to the CC?

yes

T/F: the ROS requires context

F

8 elements of HPI

1) onset

2) timing

3) location

4) quality

5) severity

6) modifying factors

7) associated Sx

8) context

what should you always start HPIs with?

age and sex of patient

T/F: the HPI does not have to be in complete sentences

F2

T/F: the CC counts as an element of the HPI

F; the elements describe the CC

T/F: It's okay for scribes to misspell words because doctors do it all the time

F

If a patient says that he has the flu, do you document that in the HPI?

no; would say that patient has a runny nose and cough

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

the patient's pain is worse with palpation of area

3 primary methods of structuring an outpatient HPI

1) single complaint formula

2) multiple complaint formula

3) chronologic formula

which HPI structure is the most commonly used?

single complaint formula

widely accepted across multiple specialities

what HPI structure is best for patients with only 1-2 complaints not previously evaluated?

single complaint formula

what HPI structure is most commonly used in primary care?

multiple complaint formula

PCPs typically discuss every complaint or disease in detail

which HPI structure is effective for patients who have multiple complaints, routine follow up for chronic illnesses, or different treatment plans for different complaints?

multiple complaint formula

in a multiple complain formula, how is each complaint/disease documented

in a separate paragraph

the chronologic structure of HPI is best for what kind of patients?

1) patients with multiple comorbidities

2) patients who have had a significant workup or eval in past

3) established patients here for follow-up of chronic illness

what are the 8 elements of a chronologic formula?

1) age and sex

2) relevant PMHx

3) previous evaluations

4) previous treatments

5) summary of current complaints

6) elements of complaint 1

7) elements of complaint 2

8) context

what 4 elements of the chronologic formula make up the recap?

1) age and sex

2) relevant PMHx

3) previous evaluations

4) previous treatments

T/F: I don't have any responsibility with regards to the ROS because the nurses complete the ROS at my facility

F

Although the chart is documented by the scribe, it is also important for the provider to

review and approve the documentation

Fix "results of bloodwork (low hemoglobin) to make it billable

Visit to discuss treatment options for low hemoglobin

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

Pain worsens with palpatation

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

chronological structure with recap

What are the 4 most common ways ROS is obtained?

1) physician led

2) nurse led

3) patient questionnaire

4) statement that refers to HPI

T/F: the scribe is only responsible for the scribe attestation and does not need to ensure that the provider attested their chart

F; both scribe and provider must put attestation at the end of every visit