Xcribe Work 3

scribe attestation

"documented by Sonam Sehdev" acting as a scribe for Dr. ___ (date/time""

what is in the subjective information?

1. CC (main reason for visit) 2. HPI (the story of the CC) ex: what does it feel like 3. ROS (checklist of symptoms from all body systems) -> + or - checklist if have it

what is HPI and ROS

both subjective, but are different HPI = patient story all about CC (context) is in complete sentences ROS = includes things not directly related to CC, head to toe overview of patient body's symptoms phrased in form of positives or negatives

HPI writing tips

complete sentences! start is age/sex of patient, use proper grammar and spelling, can use approved abbreviations, not all 8 HPI elements will be discussed, document EVERY answer to questions provider asks, order of HPI doesnt matter, but group related info together

where does subjective info come from?

directly from patient giving the history (most cases is the patient but not in the case of young children or very old people)

billing and CC

ex: Im here for checkup for diabetes -> write is 3 month diabetes management visit or evaluation ex: lab results -> discuss treatment options for elevated TSH ex: medication refill -> evaluation of medication management for HTN

what is the CC

has to have at least 1 CC, for billing need at least 1 CC

HPI Phrasing

patient says started Monday -> symptoms began 3 days ago it got better -> symptoms improved (avoid "got") hurts when touch it -> worsened by palpation of area nothing makes it better or worse -> no modifying factors my sister has the same cold -> positive sick contact with sister who had similar symptoms I throw up when I eat or drink-> vomiting is exacerbated by PO intake (by mouth) it feels like a fizzing soda -> chest pain is described as a "fizzing soda" sensation I have the flu -> pt has running nose and cough (do not document self diagnoses)

ways ROS can be obtained

physician led, nurse led (nurse does it prior, monitor for discrepanies like tell you that have fever, report to nurse), patient questionnaire, statement that refers to the HPI "ROS per HPI, otherwise negative. "

examples of HPI context

risk factors related to the complaint, if patient had similar symptoms in past, if patient had any prior testing, medical histories, surgeries, social habits related

What is the Review of Systems (ROS)?

simple list of positive and negatives (comprehesive) includes all symptoms patient mentions, ROS must never contradict since they are both subjective all ones in HPI must be in ROS, can have some more too ONLY document the symptoms the doctor asks about or pt tells us about can't make assumptions! physician led ROS

HPI structure

1. single compliant formula = most commonly used structure, best used for patients who have 1-2 complaints that have not been previously evaluated -> go into HPI elements 2. multiple compliant formula = mostly used in primary care, multiple CC, routine follow up for chronic illness, diff treatment plans for diff complaints (each CC has own paragraph) -> if New, elements .. if chronic, status update -> meds, lifestyle changes, labs 3. chronologic formula -> COMPLEX STORIES = patients with multiple comorbidities ( historical relevant issue first that are related to CC, then go into new complaints so dive into elements)

HPI elements (content) Only Tall Lads Quit Soccer Matches And Cry

8 possible elements: - onset = when did CC start? (don't use days of week, instead say how many days ago it was) - timing = how often is the CC present? constant, intermittent = comes and goes, waxing and waning is changing in intensity but always there) - location = where is CC? laterally, directional terms, quadrants , be specific! - quality = what does CC feel like? what is it like? sharp, aching, cramping - severity = how bad is it? rate pain on scale - modifying factors = what makes it better or worse? to change CC? - associated symptoms = symp occuring accompany to the CC or pertinent negatives = symp a patient does not have. Denies! - context = is anything else important ? sim symp in past? PHx, previous workup