CC and HPI

If the patient can't describe the location of the pain, ask them to point to where the pain is

What if patient can't describe location?

Alleviating factors

What makes symptoms better? Degree of improvement?

aggravating factors

What makes symptoms worse? Document specifically how symptom changes for worse

laundry list question

What type of question can you use, if patient unable to describe it?

Intersperse open-ended and more focused questions

What type of questions initially at the beginning of HPI interviews?

chronology

When did this start? How has it changed or developed with time?

NO -- this is fraud

are you able to document a sx if the pt didn't mention it or you did not ask about it?

1. Primary SYMPTOM that made the patient seek care 2. ALWAYS includes the duration 3. Most common error made is using a diagnosis as a chief complaint

components of a CC

Discuss need to take occasional notes can't take notes verbatim

early in the interview, what should you tell the pt.?

worsening joint pain x 2 days, etc.

example of chronic problem as CC

ex. the severe chest pain began while the patient was hunting outside in cold weather

example of setting relationship to other things

Size of lesion

history vs. PE description different size coins common fruits or vegetable

add new symptoms to the story as appropriate

how do you add additional symptoms into the chronology?

How would you describe the....?

how do you ask a patient a quality question?

1. Document any pertinent negative symptoms after relevant positive symptoms OR 2. Document all pertinent negatives at the end of the body system as a list (*I prefer)

how do you document associated manifestations?

1. Always document left or right when applicable 2. Be as specific as possible per patient's description

how do you document location?

1. Use of appropriate medical terms 2. Ex: Pt states that she feels her heart beating fast and skipping beats

how do you document quality?

Have patient take you back to beginning of cc duration and tell you what has been going on since

how do you start an HPI interview?

in the pt.'s own words

how is the cc usually recorded?

Brief & concise

how long are chief complaints typically?

Worsening ____________ x ____________________

if the chief complaint is a chronic problem, how do you determine duration?

Frequency

intermittent or constant

no

is the CC always the first thing the pt. states?

severity of symptom

pain scale

amount of substances

quantify whenever possible: 1 cupful; enough to soak 2 bath towels; etc. # of tampons/pads

Positive symptoms

symptoms the patient is experiencing

Pertinent negatives

symptoms the pt denies having

1. # of hospital admission (only for inpatient documentation) 2. Patient's name 3. Age 4. Race/ethnicity 5. Gender 6. Pertinent/significant PMHx 7. cc with duration

what are the components of an introductory statement

1. Positive symptoms 2. Pertinent negatives

what are two subsets of associated manifestations?

Need to consider what could be causing the patient's symptoms to ask the right questions AKA Differential Diagnosis (DDx)

what do you base associated manifestation questions on?

Chronology --> Start story at time of onset to current presentation

what forms the basis of the story? How?

WHO? WHAT? WHEN? WHERE? HOW? usually answered with the 7 factors of HPI

what general questions does the HPI content answer? How are these usually answered

worker's compensation cases

what is a special circumstance in which you would document specific dates?

pt. may be vague (ex. "I don't feel well) --> may be an uncomfortable topic

what is an example of a case in which the CC is not the first thing the pt. states?

1. Introductory statement 2. Body of story 3. Pertinent background information 4. Closing information/statement

what is the format of HPI documentation?

relates time prior to admission (PTA) OR prior to arrival (PTA) Document specific dates in special circumstances

what is the preferred method of documenting time in the chronology section?

always include a duration

what should you always include with a CC?

Avoid documenting days of the week

what should you avoid documenting for time in the chronology section?

Make sure you have established purpose of visit early in the interview

what should you do early in the interview (for chief complaint)?

If patient answers with a diagnosis, need to ask about their specific symptoms

what should you do if a pt responds with a diagnosis as their CC?

If a pt. has many CC, you can try to go through and figure out the most serious/acute Generally you can only get through 1-3 complaints

what should you do if the pt. has many CC?

just put what they say in quotes ex. worsening left foot pain x "long time"

what should you do if the pt. is not sure of a duration

Quality is more helpful in the differential diagnosis

which is more helpful in the DDx, quality or quantity?

Document quality before quantity

which should be documented first: quality or quantity?

Becomes the timetable for the story you're building in the history of present illness (HPI)

why is it important to always include a duration in the CC?

different types of qualities for pain, etc. can indicate different disorders

why is quality more helpful in DDx than quantity?

1. Gives you time to think about other questions may need to ask 2. Insures you have the patient's story right 3. Keeps you organized 4. Provides focus 5. Good transition with HPI before moving on to PMHx

why is summation helpful at the end of HPI?

quality

Description of the symptom/complaint

Still be specific in documentation Ex: Patient denies worsening of pain with food, movement, exercise, or palpation.

How do you document when there is nothing that made it worse or better?

1. Even if you are rushed, do not show it 2. Briefly look over the chart beforehand 3. It is not necessary to gather information in the order that you will document 4. Clarify when you need to - admit that you are confused 5. Address emotional aspects of history: fear, anger, etc. 6. Trust the patient's history, but verify 7. Listen to the patient

Hx Taking Guidelines

body of HPI

Tells the story of the cc from beginning to end of duration Interweaves all 7 factors in chronological order

setting

Where was the patient at onset of What were they doing at onset of symptom? Relationship to what other things?

only one

how many Sxs are typically in a CC?

radiation characterization: deep/superficial; localized/diffuse

what additional questions should you ask about location of symptoms?

1. Too many closed ended questions 2. Leading questions 3. Shopping list questions

what are some things to avoid in an HPI interview?

1. severity of symptom 2. amount of substances 3. frequency 4. size of lesion

what are some ways to enlist quantity from a pt.?

Add new Sxs in as they as the story goes on and ask more questions -Any new Sx, ask a mini 7 factors on that

•s patient introduces a new symptom into the story, what do you need to ask next?

setting chronology location quality quantity aggravating/alleviating factors associated manifestations

7 factors of HPI

pertinent background information

Any information from PMHx, personal/social or family hx that is PERTINENT to the cc Any previous diagnostic tests performed as an outpatient in relation to the cc

associated manifestations

Ask about common symptoms usually related to the chief complaint and document if present or not

location

Bodily location of symptom

history of present illness (HPI)

Builds on the chief complaint by telling the chronological story of the events that led up to patient's arrival Duration is the timeline of story

"Symptom" x Duration

CC =

closing information/statement

Events that occurred in office/ED immediately prior to admission or arrival Closing statement that includes reason for admission in the hospital setting. Can be reason why patient presented to the office in the clinical setting