ED Course 3: HPI & ROS

T/F chief complaint is an HPI element

False; CC will be incorportated into your HPI but the elements help describe the CC

what is a chief complaint

the main reason for a patient's visit/ the main symptom

Onset

when the symptoms started; documented using time frames/date/times; no days of the week.

example: today, this morning, 2 hours ago, 8:00, 7 days ago, yesterday, a few days ago, 9/13/22

timing

when the symptoms actually occur

example: constant, intermittent, waxing and wanning, nocturnally, occasional

Quality

description of how the symptoms feel (usually pain)

example: sharp, shooting, burning, cramping, ""feels like an elephant on my chest"", ""feels likes an icepick to my brain"

Location

where the symptoms are located on the body (usually pain) Example: RLQ abdominal pain, epigastric abdominal pain, HA behind the right eye, Generalized head ache

Severity

How bad the pain is either on a 0-10 scale or mild, moderate, severe scale

Associated symptoms vs. pertinent negatives

Associated symptoms: Symptoms that are related to the cc that the patient has

Pertinent negatives: Symptoms that are related to the cc that the patient denies having example: CC of SOB

Example: Patient has assocaited symptoms of cough and wheezing but denies any chest pain or fever.

Modifying factors

Does anything change the patients symptoms to be better or worse?

Example: Patient's pain was improved with Ibuprofen and exacerbated with movement. Or Patient's symptoms were unchanged by the Ibuprofen.

Context

anything else important to understanding the CC such as MOI, risk factors, similar symptoms, prior test

Example: Patient has no history of recent travel, sick exposures, head injury, or blood thinner use.

What should be included in the first sentence of an HPI?

Age and sex, CC, and onset

T/F HPI must be in complete sentences

True; they need to be professional accurate paragraphs

T/F HPI needs to be word from word what the patient said

False; we are telling the same story the patient told us, but we are writing it like a doctor would talk

T/F It makes more sense to put information out of order when discussing time lines

False; chronological order makes more sense when discussing time lines. Always tell the story in the way that makes the most sense

T/F HPI's can come from someone other than the patient

True; we can have an independent historian when needed such as a family member, friend, EMS personnel, or a caregiver

T/F you can make your own abbrevations as long as you know what they mean

False; all abbreviations need to be APPROVED MEDICAL abbrevations

how do we write 'to touch'

to palpate, palpation

how can we write 'to worsen'

to aggravate or to exacerbate

T/F HA can be charted under the GI system on ROS

False; HA should go into the neurological body system (or occasionally HEENT / Head,eyes,ear,nose,throat system)

T/F ROS can include not relevant symptoms

true; as long as the symptoms are current they can be included on ROS, not the HPI though

What is a caveat statement?

Describes why we are limited in information usually when a patient is AMS/unrepsonsive

Example: A complete ROS is unable to be obtained due to patient's condition

What is an attestation?

A statement that should be included on every chart stating who we are as scribes, why we have access to the document, and that everything written is a reflection of the provider's work/thought process while also explaining the providers are liable for everything written on the document.

T/F the ROS contains context to what is wrong with the patient

False; the ROS only contains a list of the symptoms the patient current has or does not have

What is the following element?

"10/10 pain""

severity

What is the following element?

"Sharp"

quality

What is the following element?

"pain is worse with exertion""

modifying factor

What is the following element?

"The pain is constant""

timing

What is the following element?

"It hurts right here on my right side"

location

What is the following element?

"I think it started about 2 hours ago""

onset

What is the following element?

"I am also having some nausea and I think intermittent fevers"

associated symptoms

What is the following element?

"I had a stress test done last year and it was normal. My cardiologist's name is Dr. Singh"

context

List 3 differences between the HPI and the ROS

1. The HPI is a paragraph while the ROS is a list

2. The HPI only includes info pertinent to the CC while the ROS includes all symptoms discussed head to toe

3. The HPI includes relevant context while the ROS is only +/-

List 2 similarities between the HPI and the ROS

1. They are both subjective

2. The include information coming from the patient