Charting HPI for the Medical Record Health care

Charting HPI for the Medical Record

Health care personnel play a major part in contributing to and maintaining patient records. These records document what the patient says, the evaluation and the treatments given to patients. Accurate and complete patient records ensure accurate and complete medical care.

Patient records contain many facets of the patient encounter: Personal information or data Information on the physical and mental condition of a patient A patient's complete medical history A record of the medical care provided to the patient Information regarding future medical care for the patient. Records must be properly prepared and maintained as they serve as communication tools as well as legal documents. They play a role in patient and staff education and can even be used for quality control and research purposes.

OBJECTIVE DATA DEFINITION: not influenced by personal feelings, interpretations, or prejudice; based on facts; unbiased. (Dictionary. com)

Objective Data should only be viewed through the subjective lens of the patient.

KEY POINTS Objective Data should never overrule subjective data; only confirm it. Objective Data should be used a a guide or map to determine route of care. Objective Data should be used as a general indicator of progress Objective Data tends to be more valued by younger providers and patients. Objective Data can very often be inaccurate or misleading.

EXAMPLE A medical record that contains the following note: “Patient go out of bed and walked 20 feet without shortness of breath. ”. . . is MUCH clearer and objective than: “Patient got out of bed and felt fine. ”

SUBJECTIVE DATA (DESPITE WHAT LITERATURE MAY TELL YOU THIS IS VERY VALUABLE INFORMATION!) DEFINITION: existing in the mind; belonging to the thinking subject rather than to the object of thought (Dictionary. com)

KEY POINTS Objective Data should never overrule subjective data; only confirm it. Objective Data should be used a a guide or map to determine route of care. Objective Data should be used as a general indicator of progress Objective Data tends to be more valued by younger providers and patients. Objective Data can very often be inaccurate or misleading.

Use the patient’s exact words rather than your own interpretation of them.

EXAMPLE If a patient says, "My right knee feels like it's thick and full of fluid", then that is what should be written down. A patient's words should not be rephrased, no matter how odd the words sound. • Make sure to put whatever the patient says in quotation marks. In SOAP charting, this is the SUBJECTIVE

HISTORY OF PRESENT ILLNESS (HPI)

HPI: The History of Present Illness (HPI) is used to describe the status of the symptoms or clinical problems from time of onset or since the previous encounter with the physician. Some form of HPI is required for every medical encounter.

HISTORY OF PRESENT ILLNESS (HPI) Seeks to provide SUBJECTIVE information concerning the chief complaint(s) that are the focus of the visit.

MEASURED IN 8 GENERAL CATEGORIES

THE 8 HPI CATEGORIES: (memorize them) 1. Location 5. Quality Where is the problem? Describe it 2. Duration 6. Timing How long? When? 3. Severity 7. Modifying Factors How bad? What makes it worse or better? 4. Context? 8. Associated Signs and Symptoms What makes it occur? What else happens?

EXAMPLE: HPI: Patient complains of chest pain (location), which began three hours ago (duration). Pain has been off and on since that time with each episode lasting two to three minutes (timing). The pain is described as “crushing” (quality) and at times is rated as an eight on a scale of one to ten (severity). The pain occurs with minimal exertion (context) and is associated with nausea and shortness of breath (associated signs and symptoms). The pain was relieved with sublingual NTG in the ambulance (modifying factors).

CHARTING TIP 101 1. Learn to ask the question associated with the 8 categories 2. Learn to recognize in documentation the 8 categories

LASTLY. . . REMEMBER All this information for the HPI must come from the patient and is therefore considered subjective data.

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