Subjective Documentation: HPI & ROS
Subjective Information - ANSComes directly from the person giving the history. In most cases,
the patient (sometimes a parent for children or a son/daughter for elderly persons)
Objective Information - ANSComes from the provider or medical staff and includes factual
information, such as: vital signs, physical exam, laboratory and imaging results
Subjective Information Categories - ANS-Chief Complaint: Main reason for the visit
-HPI: The story of the chief complaint
-ROS: A checklist of symptoms
History of Present Illness (HPI) - ANSThe story of symptoms and events that led to the clinic
visit and summarizes the reason for the visit. The HPI is a vital component of the chart as it is
the basis for the entire workup that follows.
Review of Systems (ROS) - ANSA head-to-toe overview of the patient's body-systems phrased
in the form of POSITIVES and NEGATIVES. It includes symptoms that are not relevant to the
chief complaint. It does NOT contain context.
HPI Elements - ANSChief Complaint: The primary reason(s) that brought the patient in.
Elements:
-Onset: When did the complaint begin?
-Timing: Has it been constant, intermittent, or waxing and waning?
-Location: Where is the discomfort?
-Quality: Does it feel sharp, dull, aching, cramping?
-Severity: How bad is it? Mild, Moderate, Severe, or 0-10.
-Modifying Factors: What makes it better? What makes it worse?
-Associated Sx: Do any other symptoms accompany the complaint?
-Context: Is there anything else that's important?
HPI Context - ANS-Risk factors related to the complaint
-If patient had similar symptoms in the past—When and is there a diagnosis in the past
-If the patient has had any prior testing (and the results) related to their complaint (this may save
us from repeating the same study)
-Medical histories, surgeries, or social habits that are relevant to the current evaluation
HPI Structure - ANS1. Age and Sex
2. Complaint and Onset
3. Quality, Severity, Timing, Location
4. Modifying Factors
5. Positive Associated Sx
Subjective Information - ANSComes directly from the person giving the history. In most cases,
the patient (sometimes a parent for children or a son/daughter for elderly persons)
Objective Information - ANSComes from the provider or medical staff and includes factual
information, such as: vital signs, physical exam, laboratory and imaging results
Subjective Information Categories - ANS-Chief Complaint: Main reason for the visit
-HPI: The story of the chief complaint
-ROS: A checklist of symptoms
History of Present Illness (HPI) - ANSThe story of symptoms and events that led to the clinic
visit and summarizes the reason for the visit. The HPI is a vital component of the chart as it is
the basis for the entire workup that follows.
Review of Systems (ROS) - ANSA head-to-toe overview of the patient's body-systems phrased
in the form of POSITIVES and NEGATIVES. It includes symptoms that are not relevant to the
chief complaint. It does NOT contain context.
HPI Elements - ANSChief Complaint: The primary reason(s) that brought the patient in.
Elements:
-Onset: When did the complaint begin?
-Timing: Has it been constant, intermittent, or waxing and waning?
-Location: Where is the discomfort?
-Quality: Does it feel sharp, dull, aching, cramping?
-Severity: How bad is it? Mild, Moderate, Severe, or 0-10.
-Modifying Factors: What makes it better? What makes it worse?
-Associated Sx: Do any other symptoms accompany the complaint?
-Context: Is there anything else that's important?
HPI Context - ANS-Risk factors related to the complaint
-If patient had similar symptoms in the past—When and is there a diagnosis in the past
-If the patient has had any prior testing (and the results) related to their complaint (this may save
us from repeating the same study)
-Medical histories, surgeries, or social habits that are relevant to the current evaluation
HPI Structure - ANS1. Age and Sex
2. Complaint and Onset
3. Quality, Severity, Timing, Location
4. Modifying Factors
5. Positive Associated Sx
