HPI and Documentation Questions with Correct
Answers
Factors that make CC/HPI difficult Correct Answer-poor description
"feeling weird", common description w/ variable definition, patient
unaware that symptoms are or are not related
Patient considerations when doing CC/HPI Correct Answer-how patient
feels at specific moment, pain tolerance, gender (females often
downplay pain), cultural/upbringing
Health Literacy Correct Answer-degree a patient is able to obtain,
process, and understand health information, determines ability of the
patient to make appropriate health decisions, does not always correlate
with education level, make sure patients understand what physician tells
tehm
Psychosocial chief complaint Correct Answer-may be cited as CC or
found to be associated with it or found incidentally. rule out organic
causes. use SIGECAPS as assessment tool
SIGECAPS Correct Answer-sleep, interest, guilt/worthlessness, energy,
concentration/cognition, appetite, psychomotor (agitation/slowing),
suicide-absolutely have to document this
CC/HPI considerations Correct Answer-do not be influenced by patient-
bias or "diagnosis-bias", avoid suggesting descriptions to patient when
possible, avoid negatively worded questions, avoid technical language,
, continue to assess patient understanding and encourage questions,
summarize before moving on
Follow-up visit Correct Answer-refer to last visit and address all
symptoms that were mentioned in previous HPI. address changes,
summarize diagnostic tests, treatments?
Well-patient exam/annual exam Correct Answer-pre-exam
checklist/assessment, comment on patient's general well being, utilize
"review of symstems", address any medical problems status and tx,
assess medication therapy, address health maintenance (colonoscopy at
certain age)
Preoperative evaluation Correct Answer-comprehensive H&P that
assesses if patient is safe to undergo anasthesia/planned surgery, cc:
"preop eval" or weekend for surgery, strong focus on cardiac and
pulmonary systems, can require additional testing, address h/o problems
w/ anesthesia, educate on surgery
Presenting HPI to physician Correct Answer-address pertinent positives
and negatives, include history findings, mention suspected diagnosis but
not documented
documenting HPI Correct Answer-extension of care, reflects on me, can
help or hurt other practitioners, impact insurance coverage, impact
reimbursement for employer, may be seen by patient.
Answers
Factors that make CC/HPI difficult Correct Answer-poor description
"feeling weird", common description w/ variable definition, patient
unaware that symptoms are or are not related
Patient considerations when doing CC/HPI Correct Answer-how patient
feels at specific moment, pain tolerance, gender (females often
downplay pain), cultural/upbringing
Health Literacy Correct Answer-degree a patient is able to obtain,
process, and understand health information, determines ability of the
patient to make appropriate health decisions, does not always correlate
with education level, make sure patients understand what physician tells
tehm
Psychosocial chief complaint Correct Answer-may be cited as CC or
found to be associated with it or found incidentally. rule out organic
causes. use SIGECAPS as assessment tool
SIGECAPS Correct Answer-sleep, interest, guilt/worthlessness, energy,
concentration/cognition, appetite, psychomotor (agitation/slowing),
suicide-absolutely have to document this
CC/HPI considerations Correct Answer-do not be influenced by patient-
bias or "diagnosis-bias", avoid suggesting descriptions to patient when
possible, avoid negatively worded questions, avoid technical language,
, continue to assess patient understanding and encourage questions,
summarize before moving on
Follow-up visit Correct Answer-refer to last visit and address all
symptoms that were mentioned in previous HPI. address changes,
summarize diagnostic tests, treatments?
Well-patient exam/annual exam Correct Answer-pre-exam
checklist/assessment, comment on patient's general well being, utilize
"review of symstems", address any medical problems status and tx,
assess medication therapy, address health maintenance (colonoscopy at
certain age)
Preoperative evaluation Correct Answer-comprehensive H&P that
assesses if patient is safe to undergo anasthesia/planned surgery, cc:
"preop eval" or weekend for surgery, strong focus on cardiac and
pulmonary systems, can require additional testing, address h/o problems
w/ anesthesia, educate on surgery
Presenting HPI to physician Correct Answer-address pertinent positives
and negatives, include history findings, mention suspected diagnosis but
not documented
documenting HPI Correct Answer-extension of care, reflects on me, can
help or hurt other practitioners, impact insurance coverage, impact
reimbursement for employer, may be seen by patient.
