What is a focused health history?
The focused history starts with uncovering the major details of the current medical problem or the reason the patient has sought medical attention at this time.
What is a problem focused examination?
Problem focused exam – a limited exam of the affected body area or organ system. Detailed exam – an extended exam of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s).
What are the four levels of history type?
The four recognized levels of history are problem-focused, expanded problem-focused, detailed, and comprehensive. The number of elements documented in the progress note determines level selection.
What are the usual 3 parts of focused history?
In documenting a focused history and performing a focused physical examination, you need to explore the chief complaint, the history of the present illness, the past medical history, medications and allergies, the family history and social history, the occupational history, and the sexual history that are relevant to …
What is a focused history?
Focused history taking is focusing on one main complaint of the patient in history of present illness, and attempting to collect all related details in other parts of history.
What does HPI mean?
History of Present Illness
History of Present Illness (HPI): A description of the development of the patient’s present illness. The HPI is usually a chronological description of the progression of the patient’s present illness from the first sign and symptom to the present.
What does timing mean in HPI?
Timing: Timing demonstrates when the patient is affected most by his or her chief complaint. One way of giving credit for timing that is not often used is looking for events that demonstrate timing.
What does problem focused mean?
Problem-focused coping targets the causes of stress in practical ways which tackles the problem or stressful situation that is causing stress, consequently directly reducing the stress. Problem focused strategies aim to remove or reduce the cause of the stressor, including: Problem-solving. Time-management.
What is the difference between problem focused and expanded problem focused?
Q: What is the difference between a detailed exam and an expanded problem-focused exam? Problem-Focused – A limited examination of the affected body area or organ system. Expanded Problem-Focused –A limited examination of the affected body area or organ system and other symptomatic or related organ system(s).
What are the elements of health history?
There are four elements of the patient history: chief complaint, history of present illness (HPI), review of systems (ROS), and past, family, and/or social history (PFSH).
What is included in a focused history?
What are the requirements for problem focused history?
The following table shows the individual requirements for each level of history. The Problem Focused History is the lowest and least descriptive level of history. This history requires only a chief complaint and a Brief HPI (which requires one to three HPI elements). No ROS or PFSH are required.
What is the purpose of a health history?
The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions.
What does expanded problem focused examination stand for?
An expanded problem focused examination is a limited examination of the affected body area or organ system and other symptomatic or related organ system(s) (two to seven body areas or organ systems), according to the 1995 E/M Documentation Guidelines.
What do you mean by history of present illness?
History of Present Illness (HPI): A description of the development of the patient’s present illness. The HPI is usually a chronological description of the progression of the patient’s present illness from the first sign and symptom to the present. It should include some or all of the following elements: Location: What is the location of the pain?