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HPI and Documentation Exam Questions
With Correct Answers
Factors that make CC/HPI difficult - 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 - answer✔✔how patient feels at specific moment,
pain tolerance, gender (females often downplay pain), cultural/upbringing
Health Literacy - 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 - 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 - answer✔✔sleep, interest, guilt/worthlessness, energy, concentration/cognition,
appetite, psychomotor (agitation/slowing), suicide-absolutely have to document this
CC/HPI considerations - 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 - 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 - 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 - 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 - answer✔✔address pertinent positives and negatives, include
history findings, mention suspected diagnosis but not documented
HPI and Documentation Exam Questions
With Correct Answers
Factors that make CC/HPI difficult - 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 - answer✔✔how patient feels at specific moment,
pain tolerance, gender (females often downplay pain), cultural/upbringing
Health Literacy - 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 - 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 - answer✔✔sleep, interest, guilt/worthlessness, energy, concentration/cognition,
appetite, psychomotor (agitation/slowing), suicide-absolutely have to document this
CC/HPI considerations - 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 - 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 - 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 - 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 - answer✔✔address pertinent positives and negatives, include
history findings, mention suspected diagnosis but not documented
