ScribeAmerica course 3 review
In your own words, describe the significance of an HPI.
The HPI is the story of the symptoms and events that led to the patient's ED visit. It includes the CC and the associated Sx
How is the HPI different from the ROS?
a. HPI focuses on the story about the chief complaint and its associated symptoms
b. ROS is a checklist of symptoms. It includes the chief complaint, associated symptoms, and all other complaints that patient may have
Name five "elements" of the HPI
Onset, timing, location, quality, severity, modifying factors
Can the symptoms listed in the ROS ever contradict the symptoms described in the HPI? Why or why not?
No. Symptoms that are documented in the HPI also need to be documented in the ROS
Name the 8 of the body systems included in the ROS.
Constitutional, eyes, ENT, CV, Resp, GI, GU, MS, skin, neuro, psych, endocrine, heme/ lymph, immunological
What do you need to remember to document in the HPI and ROS for any patient that is unconscious or incapable of providing information?
HPI/ ROS limited by...
Identify the error in this sentence from an example HPI "Patient states the CP has been intermittent since Thursday".
We do not document days of the week in the HPI. Instead, we would count back the number of days and document this numerically
Why is it important to remember to document if the patient has had similar symptoms in the past?
Because it is less likely that their current symptoms are life threatening if they have survived similar symptoms in the past
Name one detail that is important to document if the patient has been evaluated in the past for a similar complaint.
What symptoms prompted the prior evaluation? How long ago did the prior evaluation occur? Who did they see? (Name and specialty) What treatment did they receive? Did it help what diagnosis was given? Any prior test results?
What should you focus on when writing an HPI?
Documenting the answers to every question asked by the doctor
Which is the first item in the formula for writing and HPI?
Chief complaint and onset
What does MOI stand for in a Trauma HPI?
Mechanism of Injury
True or False: In the ROS, you should document "All other systems negative except as mark" for every patient
Based on your knowledge from Day 2, Why should you always pay special attention to the complaints of Chest Pain and SOB?
Direct concern for MI
Name 3 past surgical histories that indicate that the patient has a history of CAD.
Angioplasty, CABG, stents
What is the difference between cardiac stress test and a cardiac catheterization?
a. Cardiac catheterization - insertion of a catheter with ejection of dye into the coronary artery, used to diagnose CAD
b. Stress test - measures the hearts ability to respond to physical stress to determine if there is adequate blood flow to your heart during increasing levels of activity. There are two different types of stress test
- Exercise (treadmill) stress test
- Nuclear stress test is for patients with a medical problem that prevents you from exercising
What are the risk factors for an MI?
CAD, HTN, DM, dyslipidermia, smoking, FHx of CAD less than 55y/o
What are the risk factors for a PE?
Known DVT, PMHx of DVT or PE, FHx of DVT or PE, recent surgery, CA, Afib, immobility, pregnancy, BCP, smoking
What are the risk factors for a CVA?
HTN, HLD, DM, Hx of TIA/CVA, smoking, FHx of CVA, Afib