Scenario 1-Ear Pain - Lecture notes 2 PDF

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Lecture notes on medical scribe...

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Scenario 1-Ear Pain Welcome to the classroom training mock chartin chart by watching the video link below, and com based on the information given. A few things to remember! Your HPI should read like a story and only be rele includes the elements listed in the HPI PLUS any The number 1 thing to remember is that this is a instructions to get accustomed to charting. Your preferences which absolutely supersedes what **For this reason, you are ONLY to document wh If a provider says an entire body system is "norm other major findings in that section. If a body sys must document "not addressed". Once you get to your site, your provider may hav with your provider's preferences or a macro/tem exam performed by your provider. How ever in tr templates." **

Email address * [email protected]

History of Present Illness (HPI) * Subjective story of what brought the patient in. Answer submitted

issue in ear(bead inside), healthy background.

Feedback Here is a sample HPI for this scenario: Patient was brought in by his mother for possib by Daycare around 1:15pm today and notied th ears after playing with beads. He was pulling at mother. She denies any prior hospitalizations an has not had cough, congestion, or vomiting rec mother. Patient's mother states no one actually patient's crying and pulling at ears began short Score out of 12 is calculated by 1 point awarded CC: Ear Pain Onset: Today, around 1:15pm Location: Ears Pertinent Negatives - cough -congestion - vomiting Context -was playing with beads -Pulling at right ear and crying -No hx of prior hospitalizations -Immunizations UTD Spelling Grammar

Let's break down the HPI The HPI is comprised of elements, details that describe onset, timing, severity. Answer the questions below.

What is the "Chief Complaint" for this 1. Headache 2. Neck pain 3. Chest pain 4. Upper Back pain 5. Ear Pain 6. Lower Back pain 7. Nose/Throat pain

What is the "Location" for this HPI 1. Head 2. Neck 3. Chest 4. Upper Back 5. Lower Back 6. Ears 7. Skin

What is the "Onset" of this HPI 1. This afternoon

Palpitations

Back Pain

Respiratory ONLY list what the patient says yes/no to. If not addres gain a point

Positive for

Negative for N

Cough

Wheezing Shortness of breath

Correct answers Positive for

Cough

Gastrointestinal/Genitourinary ONLY list what the patient says yes/no to. If not addres gain a point

Positive for

Negative for N

Abdominal Pain Vomiting

Diarrhea

Correct answers Positive for

Abdominal Pain

Vomiting

Skin ONLY list what the patient says yes/no to. If not addres gain a point

Positive for

Negative for N

Rash

Abrasion

Laceration

Past History (Medical, Surgical, Family) Positive for

Negative for

Seasonal Allergies Previous hospitalizations Asthma

Correct answers Positive for

Seasonal Allergies

Asthma

Social History (siblings, school, vaccines, br Yes

Siblings Brought in by Mother Goes to Daycare Sick contact Vaccinations UTD

No

N...