Lecture 2: CC, HPI, and PMH
Lecture Objectives
Introduction to performing an H+P
Introduction to medical documentation
Components of medical history
- Identifying data
- Chief complaint
- History of present illness
- Past medical history
History and Physical Overview
Having a conversation(with a purpose) with the patient and then examining their body
AKA eliciting a health history and performing a physical exam
AKA the bedside skills of medicine
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Medical Documentation
Multiple purposes:
A basis for billing
A form for transferring clinical information
A legal document that describes events that occurred
, A guide to clinical reasoning
Comprehensive H+P: all elements of health history
Directed (focused): adjusted for scope of problem and extent of knowledge of the patient
- Directed H+P
- SOAP note
- Post-op note
- Etc.
Comprehensive H+P
Used for:
- New patients
- Admitted patients
- Strengthens clinician-patient relationship
- Baseline for future assessments
- Health promotion
Our focus for this course
Takes about 2-21/2 hours to complete
Focused H+P:
Used For:
- Established patients
- Urgent/emergent care patients
- Addresses focused concerns, symptoms
- Addresses concern or problem concisely
Subjective Data
History info gathered from pt. or family
Objective Data
Data collected from physical exam & tests
Lecture Objectives
Introduction to performing an H+P
Introduction to medical documentation
Components of medical history
- Identifying data
- Chief complaint
- History of present illness
- Past medical history
History and Physical Overview
Having a conversation(with a purpose) with the patient and then examining their body
AKA eliciting a health history and performing a physical exam
AKA the bedside skills of medicine
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:00
/
0:15
Full screen
Brainpower
Read More
Medical Documentation
Multiple purposes:
A basis for billing
A form for transferring clinical information
A legal document that describes events that occurred
, A guide to clinical reasoning
Comprehensive H+P: all elements of health history
Directed (focused): adjusted for scope of problem and extent of knowledge of the patient
- Directed H+P
- SOAP note
- Post-op note
- Etc.
Comprehensive H+P
Used for:
- New patients
- Admitted patients
- Strengthens clinician-patient relationship
- Baseline for future assessments
- Health promotion
Our focus for this course
Takes about 2-21/2 hours to complete
Focused H+P:
Used For:
- Established patients
- Urgent/emergent care patients
- Addresses focused concerns, symptoms
- Addresses concern or problem concisely
Subjective Data
History info gathered from pt. or family
Objective Data
Data collected from physical exam & tests
