History of Present Illness (In depth)
This is the "story" summarizing why the patient came to receive treatment
This elaborates on the chief complaint
Includes 8 elements
Includes any past medical or past surgical history pertinent to the CC
(If a patient presents complaining about abdominal
8 Elements of HPI
Timing
Location
Duration
Context
Severity
Quality
Modifying Factors
Associated Signs and Symptoms
Location
Describes where on the body the pain or symptom is located
Some examples are: LLQ of the abdomen, lower back, right knee, head, or central chest
There may not be a location associated with the complaint so if a patient presents complaining of cough, the s
Quality
Describes what type of pain the patient is experiencing
The scribe will document the adjective that the patient uses to describe the pain, sometimes quotations will be used to state verbatim how the patient describes their pain
Dull, sharp, cramping
Severity
Describes how the patient rates the pain
Do not confuse this with quality
Usually a scale from 1-10
Or mild, moderate, to severe
Duration
Describes the characteristic of pain since the onset in relation to time
Intermittent
Waxing/ Waning: The pain never really goes away but increases and decreases in waves
Constant since onset
Pain occurs in 10-15 second intervals
Do not confuse with timin
Timing
Describes the onset of pain or when the pain began
Onset: Yesterday, Today, PTA, 1 hour ago, 3 hours ago, 1 month ago
Context
Describes what the patient was doing when the pain started
The patient finished dinner when the abdominal pain began
The patient was running when she became short of breath
The pain woke the patient up from sleep
The patient was moving furniture when he h
Modifying Factors
Anything that makes the pain better/worse/unchanged
The patient took over the counter pepto with no relief
The patient took two 81 mg ASA PTA with no change in symptoms
The pain is exacerbated with movement but improves while sitting
The pain is worse aft
Associated Signs and Symptoms
All pertinent positive and negative symptoms that accompany the chief complaint
A patient presents c/o RUQ ABD pain. Associated Sx include fever, nausea, and diarrhea. Pt denies vomiting, diaphoresis, or skin rash
It is important for the scribe to documen
Using medical terms/ not layman's terms
use patient (pt) and not he or she, use states or reports
if the scribe wants to document exactly what the patient says then they must use quotes, usually these are used to describe the quality of pain
Proper Terms for HPI
complains of (c/o), reports, admits, presents with, denies, states, intermittent, increase, decrease