Anatomy of a Chart
What does HPI stand for?
History of the Present Illness
The pt says they fell and injured their left wrist. Where does it go?
HPI
What is the medical term for a local collection of purulence?
Abscess
What is rhinorrhea?
Runny nose
In the PE, in which system would you document someone having a rash?
Skin
Objective (As per the provider's examination!)
Your provider says the pt has "tenderness of the left wrist". Where does it go?
Physical exam (PE)
What is the medical term for redness?
Erythema
What does NKDA stand for?
No known drug allergies
In the PE, in which system would you document someone having nystagmus?
What must be included to start your HPI?
Provider name, time of evaluation, patient age, chief complaint.
Your physician orders an XR for the pt's arm. Where does it go?
MDM
What does NPO stand for?
Nothing by mouth (Nil per os)
What does PE stand for (not physical exam)?
Pulmonary Embolism
In the PE, in which system would you document someone having edema of the BLEs?
Musculoskeletal or Cardiovascular
In what part of the chart should you include the symptoms reported by the pt?
Review of Systems (ROS)
The provider goes and speaks to the pt again to see if their pain has improved. Where would you document this?
Re-evaluations.
What is a cholelithiasis?
Gallstone
What organ has a discoloration if they have scleral icterus?
Eyes
In the PE, in which system would you document someone having CVA tenderness?
Abdominal
If a provider speaks to another specialty about a pt, where should you document it?
MDM
Your provider sees a pt, and the plan of care is incomplete when their shift ends. The next provider arrives. Where should you document moving forward?
Transfer of Care
What does DKA stand for?
Diabetic Ketoacidosis
What is the term for painful swallowing?
Dysphagia
In the PE, in which system would you document someone having hemotympanum?
HENT