HPI – Flashcard
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Forms of Data Collection
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1. Triage Notes 2. Primary Nurse 3. Registrar 4. Nursing Home Records 5. MICU (Mobile Intensive Care Unit) Medical Record 6. Historical Data 7. Other Facilities 8. Medical Alert tags/wallet cards 9. Primary Medical Doctor (PMD) Records 10. Active Listening
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Physician Note
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-Not only a chronicle of the patient's ED visit but also a legal document -Record pertinent positive and pertinent negatives
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Physician Note: SOAP
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1. Subjective: what the patient, family member, etc. tells the provider 2. Objective: the physical exam, vital signs, and test results 3. Assessment: review of subjective and objective data to determine a presumptive diagnosis 4. Plan: the diagnostic, therapeutic and educational components, including discharge instructions
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Physician Note Contains:
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1. History of the Present Illness (HPI) 2. Review of Systems (ROS) 3. Past History 4. Physical Examination 5. Diagnostics 6. Emergency Department Course and Treatment 7. Plan and Follow Up 8. Prescriptions 9. Discharge Instructions 10. Diagnosis 11. Coding
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History of Present Illness (HPI)
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This section contains the patient's name, age, sex and chief complaint. The HPI expands on the chief complaint and contains eight components
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Quality
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characteristic of a symptom ex: sharp, dull, burning, pressure
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Location
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area of body/localized area ex: chest pain, headache
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Timing
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a statement of the onset and progression of the symptoms. Can be described as a time of day, day of the week, month or year, if the pain is continuous or intermittent.
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Duration
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how long has the problem been occurring ex: 2 hours, 3 days
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Severity
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intensity or on a number scale, ex: pain #3 on a 0-5 scale; temperature as high as 102; mild/moderate/severe pain. Could also refer to a patient's wincing or inability to bear weight.
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Modifying factors
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things that the patient/caretaker did to make the problem better, ex: fever relieved with Tylenol; chest pain relieved with nitro
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Associated signs or symptoms
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symptoms associated with the patient's chief complaint. for example, patient's chief complaint is abdominal pain. Otherwise: (+) fever, (+) nausea, (-) dyspnea
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Social Context
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situational factors. This is a given component of the HPI statement.
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Pre-Hospital Treatment
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This treatment may be provided by BLS or ALS and is documented at the end of the HPI as "in the field" or "en route to the ED"
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Basic life support (BLS)
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EMTS who are authorized to perform skills such as first aid, application of emergency oxygen, cardiopulmonary resuscitation (CPR), and early defibrillation with an automated external defibrillator
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Advanced life support (ALS)
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Paramedics who are authorized to administer certain life-sustaining medications, apply electrical defibrillation, establish intravenous therapy and utilize advanced airway skills at the scene of an emergency under the supervision of a physician
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Physician takes call
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"MICU control by me. Patient treated with ____ en route to the ED."
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Another physician takes call
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"MICU control by Dr. _____. Patient treated with _____ en route to the ED."
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Immediate attention
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"Patient required my immediate attention"; meaning 10-20 minutes or specify (ex: immediately upon respiratory distress)
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Primary medical doctor (PMD)
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List the patient's PMD and other specialists at the end of the HPI
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Patient unable to speak
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Ex: "PMH: Unobtainable"
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Pediatric patients
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For patients under 10, document that the caretaker provided the history, not the patient him/herself
