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How to Save Short Medical History in DOC

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Evan, a GP registrar, is speaking with a patient about their health issue. The patient reports experiencing diarrhea for the past two to three weeks, stating that prior to this, their bowel movements were normal, occurring every couple of days without problems. They describe the diarrhea as frequent but similar in color and consistency to their usual stool. When asked if there is any blood in the stool, the patient expresses surprise that they hadn't mentioned this detail yet, indicating that there may be blood present. Evan takes notes to facilitate documenting the patient's condition later.

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What are the 7 dimensions of HPI?

Any patient interview should start with the HPI (history of present illness, which makes up the 7 dimensions: Chronology, Location, Quantity, Quality, Aggravating and Alleviating factors (what makes the problem Better or Worse), Setting, and Associated Manifestations.

How do you document the history of present illness?

It should include some or all of the following elements: Location: What is the location of the pain? Quality: Include a description of the quality of the symptom (i.e. sharp pain) Severity: Degree of pain for example can be described on a scale of 1 - 10. Duration: How long have you had the pain.

How do you chart past medical history?

How To Properly Document Patient Medical History In A Chart Presenting complaint and history of presenting complaint, including tests, treatment and referrals. Past medical history diseases and illnesses treated in the past. Past surgical history operations undergone including complications and/or trauma.

Where is medical history stored?

Most GP medical records are a combination of paper records (such as Lloyd George records) and digital records, either stored on the surgerys computer system, in filing cabinets or stored externally at a document storage facility.

What are examples of history of present illness?

The history of present illness, or HPI, is part of the subjective portion of the patient interview and provides detailed information on the patients chief complaint. For example, if someone presents with a cough, the HPI would record details about the cough from the patient in their own words.

What are the 8 HPI elements?

The history of present illness (HPI) component of an E/M service is comprised of eight elements: location; quality; severity; timing; duration; context; modifying factors; and associated signs and symptoms.

What is a brief medical history?

A record of information about a persons health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.

What are examples of HPI components?

Some examples include: fever and chills that accompany a chief complaint of stomach pain; sore throat and sinus pain that accompany a cough; numbness and tingling accompanying pain in the leg.

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Save Short Medical History in DOC