Day 3 Scribe America Training: HPI and ROS
latest updated questions with expert
solutions.
How many body systems are there - answer 14
Name body systems - answer integumentary, psychological, neck,
lymph, endocrine, GU, GI, cardiovascular, respiratory, eyes, ENT,
musculoskeletal, neurological
G/P/A - answer Gravida- how many times woman has been pregnant
Para-How many viable children were born
Abortion- number of elective/miscarriage abortion
If twins then P will be greater than G.
What to learn from this PPT - answer Understand the importance of the
History of Present Illness
Learn the basic elements of writing an HPI
Analyze an example HPI to understand each component
Learn how to write an HPI like a physician
,Read example HPI's
Learn the difference between the HPI and ROS
Review major Chief Complaints from Day 2
Review Common Past Medical and Surgical history
What is an HPI - answer The History of Present Illness is the story of
symptoms and events that led to the patient's ED visit.
Only SUBJECTIVE information belongs in the HPI.
The HPI is the beginning of every chart summarizing the reason for the
visit.
The HPI should ONLY include information directly related to the CHIEF
COMPLAINT and IMPORTANT CONTEXT for that patient. All other
information belongs in a different section of the chart.
Other detail of HPI - answer It is always important to document who the
historian is for the HPI. Most often the patient is the historian; however
for pediatric patients or patients incapable of speaking, always
remember to document who is providing the information.
, Sometimes a complete history is not available. In this case it is
important to document why the history is limited. For example, "HPI is
limited due to the patient's non-verbal status".
In the event that the history is limited remember to only write exactly
what you know about the patient, and specifically how you know it. For
example, "Per EMS, this patient was found unresponsive 15 min ago"
HPI Elements - answer Onset, Timing, Location, Quality, severity,
modifying factors, associated Sx, Context
Onset - answer When did the complaint begin?
timing - answer Has it been constant, intermittent, or waxing and
waning?
Location - answer where is discomfort
quality - answer does it feel sharp, dull, aching, cramping
severity - answer how bad is it? mild, med, severe 0-10
mod factor - answer what makes it better? What makes it worse?
latest updated questions with expert
solutions.
How many body systems are there - answer 14
Name body systems - answer integumentary, psychological, neck,
lymph, endocrine, GU, GI, cardiovascular, respiratory, eyes, ENT,
musculoskeletal, neurological
G/P/A - answer Gravida- how many times woman has been pregnant
Para-How many viable children were born
Abortion- number of elective/miscarriage abortion
If twins then P will be greater than G.
What to learn from this PPT - answer Understand the importance of the
History of Present Illness
Learn the basic elements of writing an HPI
Analyze an example HPI to understand each component
Learn how to write an HPI like a physician
,Read example HPI's
Learn the difference between the HPI and ROS
Review major Chief Complaints from Day 2
Review Common Past Medical and Surgical history
What is an HPI - answer The History of Present Illness is the story of
symptoms and events that led to the patient's ED visit.
Only SUBJECTIVE information belongs in the HPI.
The HPI is the beginning of every chart summarizing the reason for the
visit.
The HPI should ONLY include information directly related to the CHIEF
COMPLAINT and IMPORTANT CONTEXT for that patient. All other
information belongs in a different section of the chart.
Other detail of HPI - answer It is always important to document who the
historian is for the HPI. Most often the patient is the historian; however
for pediatric patients or patients incapable of speaking, always
remember to document who is providing the information.
, Sometimes a complete history is not available. In this case it is
important to document why the history is limited. For example, "HPI is
limited due to the patient's non-verbal status".
In the event that the history is limited remember to only write exactly
what you know about the patient, and specifically how you know it. For
example, "Per EMS, this patient was found unresponsive 15 min ago"
HPI Elements - answer Onset, Timing, Location, Quality, severity,
modifying factors, associated Sx, Context
Onset - answer When did the complaint begin?
timing - answer Has it been constant, intermittent, or waxing and
waning?
Location - answer where is discomfort
quality - answer does it feel sharp, dull, aching, cramping
severity - answer how bad is it? mild, med, severe 0-10
mod factor - answer what makes it better? What makes it worse?
