Subjective Data in the Patient's Chart
Palliative
A palliative factor is simply something that makes the pain better or seems to reduce the problem. Example: if a patient has a fever and they take Tylenol, they may notice that the fever goes away.
Timing
Any time a patient describes to the physician when the symptom(s) started, how long they have lasted, how frequently they are experienced, whether they are intermittent or reduced.
Context
Anything that doesn't fit into the other PQRSTAC elements, but is still important to the story. For example, "My stomach started hurting after I ate McDonald's for lunch."
Subjective Parts of the EMR
Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS), Past Medical/Family/Social History (PMFSH)
Associated Symptoms
Headache, dizziness, nausea, vomiting, diarrhea
Objective
Observations, exam findings, testing, results, etc. from the physician's point of view.
Quality
Quality is most often documented using quotation marks, because it comes directly from the patient's own mouth. Quality should always be directly what the patient said. "It feels like an elephant is sitting on my chest."
HPI Styles
Your HPI paragraph should be professional, clear and understandable. Avoid slang and colloquialisms Avoid abbreviations and shorthand Check your HPI paragraph for grammatical mistakes and double-check your spelling. The style of entering the HPI varies depending on the: Physician preferences Personal writing style Types of patients or their chief complaint
HPI Format
[Age and gender] with a history of [PERTINENT Hx] who presents to the ED for [CC]. [DESCRIPTION OF CC AND RELEVANT INFORMATION]. A 46-year-old male with a history of CAD who presents to the ED today for constant chest pain for the past 4 days. He reports the pain began radiating to his left shoulder and down his left arm this AM. The patient states he has felt shortness of breath with chest pain. He denies cough, nausea and vomiting, abdominal pain, or leg swelling.
Chief Complaint (CC)
a primary reason for a patient's visit to the Emergency Department. Report using the patient's own words. Most severe symptom will be considered the chief complaint.
Provocative
provokes a negative response Example: a patient states that bending over or picking up heavy objects makes their back pain worse
Radiation
where the pain travels, if anywhere, or if the problem affects any other body parts.
Region
which part of the body is affected
Subjective
Personal opinions, perceptions, assumptions, interpretations, beliefs, etc. from the patient's point of view.
History of Present Illness (HPI)
The History of Present Illness is the reason why the patient came to seek care. Think of the HPI as a story or the history of the patient's chief complaint.
Severity
When the patient experiences no pain, you will document it as 0/10 or you will state that patient has denied any pain in the HPI paragraph. When the patient experiences mild pain, you will document it as 1/10, 2/10, 3/10 or by describing the pain as mild or minimal in the HPI paragraph. When the patient experiences moderate pain, you will document it as 4/10, 5/10, 6/10 by describing it as moderate in the HPI paragraph. As a scribe you will document severity as the patients state it. The patients' answers may depend on the physicians' questions. Patients may also express the severity of their problems in a form of severity statement, which indicate the severity of the problem to the attending physician. For instance, the patient may say: "My back pain is so bad that it makes me not want to get out of bed." or "I hurt so much I cannot go to work." So, depending on the physician's question, you may document severity as 7/10, 8/10, 9/10, 10,10 by describing it as severe or by quoting the patient's severity statement in the HPI paragraph.
HPI Sources
Where will we be getting most of our information for the HPI? Patient What might be some other sources? Friends/Family Nursing home staff/records Existing records and/or prior knowledge of the clinic staff
