Can the symptoms listed in the ROS ever contradict the symptoms described in the HPI? Why or why not?
No. Symptoms that are documented in the HPI also need to be documented in the ROS.
What do you need to remember to document in the HPI and ROS for any patient that is unconscious or incapable of providing information?
“HPI/ROS limited by...”
Identify the error in this sentence from an example HPI: “Patient states the CP has been
intermittent since Thursday.”
We do not document days of the week in the HPI. Instead, we would count back the number of days and document this numerically
Why is it important to remember to document if the patient has had similar symptoms in the past?
Because it is less likely that their current symptoms are life-threatening if they have survived similar symptoms in the past.
Name one detail that is important to document if the patient has been evaluated in the past for a similar complaint.
What symptoms prompted the prior evaluation? How long ago did the prior evaluation occur? Who did they see? (Name and specialty) What treatment did they receive? Did it help What diagnosis was given? Any prior test results?
What should you focus on when writing an HPI
Documenting the answers to every question asked by the doctor
Which is the first item in the formula for writing an HPI?
Chief complaint and onset
What does MOI stand for in a Trauma HPI?
Mechanism of Injury
True or False: In the ROS, you should document “All other systems negative except as marked” for every patient.
Based on your knowledge from Day 2, why should you always pay special attention to the complaints of Chest Pain and SOB?
Direct concern for MI
Name three past surgical histories that indicate that the patient has a history of CAD.
Angioplasty, CABG, stents
What is the difference between a cardiac stress test and a cardiac catheterization?
Cardiac catheterization - insertion of a catheter with injection of dye into the coronary artery, used to diagnose CAD.
Stress test - measures the heart's ability to respond to physical stress to determine if there is adequate blood flow to your heart during increasing levels of activity. There are two different types of stress tests. Exercise (treadmill) stress test. Nuclear stress test is for patients with a medical problem (e.g. arthritis) that prevents you from exercising. They use a medication to stresses the heart (mimicking exercise)