The Medical Scribe Certificate Top Possible Revision Questions and Answers 2024

HPI - history of present illness ROS - Review of Systems PE - Physical Examination A/P - acssessment and planning CC - Chief Complaint Chief Complaint - statement or reason for the patient encounter History of present illness - detailed description of development of the patients present disease presented as a chronological story Factors in a HPI - 1. Location on body 2. Quality 3. Severity 4. Duration and Timing 5. Modifying Factors 6.Associated Symptoms 7. Context 8. Chief Complaint Context - the situation around the chief complaint Duration - how long the main complaint has been going on Timing - "constant, coming and going" Location - where on the body is the complaint Quality - what the chief complaint feels like "dull sharp" Severity - 1-10 Scale Modifying Factors - anything that makes the chief complaint better or worse Associated Symptoms - any symptoms described by the patient that are directly related to the chief complaint "no" - record as patient denies Bowel Sounds - intestinal sounds heard from auscultating over the abdomen Diffuse - generalized not localized Distention - enlarged or swollen due to internal pressure Femoral Pulse Deficit - pulse is either skipped or absent over the femoral artery