Tag: medical charting

Yo. What’s up?

I’ve honestly wanted to do a more specific post like this because it is highly searched, but I’ve also been dreading doing it.

Simply put: writing an HPI is hard. It is usually hard to find a template as everyone has their own style. Some are longer, more eloquently put and flow great. Some are short and choppy in style. It really all depends on your preferences, your provider’s preferences, and sometimes the specialty.

So, I’m going to attempt to do a general template for you. Again, most of this you just have to PRACTICE. It really is the only way to get good at HPI’s.

What is a well exam?

Ah. So glad you asked.

A well exam is usually a yearly exam for your checkups. Can be called annual exam, well exam, general medical exam, etc. Typically when you are a pediatric patient, you have many well exams in a year. For example, you will be seen at 1 week post-life, then like 1 month, 2 months, 4 months, 6 months, etc. Once you reach about the age of 2 or 3 you start seeing a pediatrician yearly. After that (especially as an adult), you should really have a comprehensive medical exam with your doctor once a year.

Now, if you have chronic conditions, you are likely going to have to see your doctor more regularly. But they can at least count one of those visits as a yearly exam which is less of a cost to your insurance.

Additionally, most adults’ jobs will give discounts if you go to your yearly exam to show you are trying to stay healthy. I don’t know why some jobs seem to care about this, but they do.

Okay back to the template

By now you should know what a SOAP note template looks like. If not, go check out my other scribe series posts. It’s all in there. If you have, I’m going to skip all the additional stuff and just focus on the HPI.

Super basic, no flare:

{First name, last name} is a {age} y/o {sex} presenting with a cc of {location if applicable} {chief complaint} which started {onset}. Symptom is described as {character/quality}, last for {duration}, and is described as a {0-10/10, severity} on the pain scale. It. {does/doesn’t} radiate to {location}, and is noted mostly at {timing}. {List of aggravating symptoms} exacerbate/aggravate {cc}. While {list of alleviating symptoms} improve {cc}. Associated symptoms include {List of associating symptoms}. {List negative associated symptoms}. There are no other concerns/complaints at this time.

It looks like this:

Mr. {Judge X} is a {55} y/o {M} presenting with a cc of {RLQ} {abdominal pain} onset {15 hours ago}. Initially, pain was around his umbilicus, but has now settled to his RLQ. It is described as {sharp}, and at first was {waxing and waning} but is now {constant}. Pain is currently rated an {8/10}. It {does not} radiate. {Hitting bumps on the car ride over} aggravated his pain. He has tried {Tylenol, Motrin, and Pepto-Bismol} without relief. Associated symptoms include {nausea, vomiting x1, low grade fever of 100.4’F at home, and chills}. {No reported hematemesis, diarrhea, hematochezia, chest pain}, DIB, or other symptoms.

Template when there are multiple complaints

So. As much as life would be really easy if there was only one complaint that someone came in with, people don’t just do that. A lot of times, they have several chronic diseases that are managed. Other times they wait a very long time before being seen, and then come in with several complaints that they would like addressed. These templates need to be a bit more broken down.

Basic, multiple complaint template:

{First name, last name} is a {age} y/o {sex} presenting for a generalized well examination.

{His/Her} first concern, {main complaint}. They first noted {his/her} {complaint} {onset}. Symptom is described as {character/quality}, last for {duration}, and is described as a {0-10/10, severity} on the pain scale. It. {does/doesn’t} radiate to {location}, and is noted mostly at {timing}. {List of aggravating symptoms} exacerbate/aggravate {cc}. While {list of alleviating symptoms} improve {cc}. Associated symptoms include {List of associating symptoms JUST FOR THIS COMPLAINT}. {List negative associated symptoms JUST FOR THIS COMPLAINT}.

You only want to add negative and associated symptoms that correlate with that complaint. This may not be a long list. That is okay.

You can then add as many similar paragraphs to additional complaints.

In regards to {his/her} {chronic condition}, they have been doing {well, poor}. They have been {compliant/non-compliant} with their medications, which include {list their medications and doses}. They have tried/incorporated {lifestyle changes} with good measure. Their last {objective finding related to this disease/condition}. {List associated symptoms if any}. {List negative associated symptoms if any}.

You can then add several similar paragraphs if they have multiple chronic conditions.

For example:

{Miss Sanchez} is a {32 y/o} {F} presenting today for a generalized well examination.

In regards to {her} {diabetes}, she has been doing {fairly well} per her reports. She has been {compliant} with her metformin and glipizide on her current regimen. She has tried to {cut out sodas and limits her caffeine intake to 1-2 coffees a day}. She additionally tries to walk around the block after work and on her lunch break. However, she has not made progress with much other changes to her lifestyle. She does not often check her sugars at home. Her last {hgb A1C was 8.0}. Today, her hgb A1C is {7.9}. She denies any {paresthesias, weight gain, eye changes, or urinary complaints}. She has not gone for her annual eye exam yet.

Things to think about per complaint:

1. Diabetes: medication compliance, diet/exercise changes, weight gain/loss, Hemoglobin A1c results (more reliable than glucose levels on a BMP), any new symptoms they are having. The three big things with diabetes is diabetic retinopathy, nephropathy, and peripheral neuropathy. Or eyes, kidneys, and tips of the extremities. They should be seen every 3 months for glucose checks, should be checking their sugars at home, should have an annual eye exam, and should have their urine monitored for protein and glucose at least yearly. Additionally, a diabetic foot exam should be performed once a year (some providers like to do it twice a year).
2. Hypertension: medication compliance, monitoring blood pressures at home, diet/exercise changes. Losing 10% of your body weight can actually resolve or improve a lot of chronic diseases (including improving diabetes and hypertension). Other things to think about include hyperlipidemia, so a yearly lipid panel check should be done as well. Overall, most of this discussion will be medication compliance and lifestyle changes.
3. Thyroid checks: The main blood test ordered is TSH, but you will also see FT3/4 also sent. Most of the patients you will see will already be on medication, and this is simply checking to make sure the medication dosage doesn’t need to be changed. As a scribe, you won’t really need to be doing much else with this information. But if the patient is being newly diagnosed, then a high TSH indicates hypothyroidism, and a low TSH indicates hyperthyroidism. Usually follow up tests such as a thyroid ultrasound would also be ordered to confirm that there isn’t anything else occurring, so add this information in if your provider likes that information in their HPI. Otherwise, the medication dosage and frequency is important along with any possible symptoms the patient is having.
4. Chronic lung complaints: Common things to add include when the last PFT was (lung function testing), last CXR, if they are on inhalers, what they are, dosage, etc; how often they are using rescue inhalers, the type of work they do, if they are exposed to smokers, if they are a smoker, things like that. Worsening symptoms include sputum production, increased coughing, and dyspnea. These patients can tend to have COPD exacerbations more frequently as the disease progresses or isn’t well controlled, and they tend to get pneumonia very easily.
5. Well Woman exam: The main thing here is when was her last exam, any prior positive HPV testing (and what it showed, such as ASCUS vs low vs high dysplasia), and if those resulted in any procedures previously. Last mammogram or ultrasound or MRI (depending on age), last menstrual period, previous pregnancies (included as GPA, or gravid, para, and abortions), age when her menstrual cycle started, if she is in menopause/when did that occur.
6. Vaccinations: These are mostly age specific. In a pediatric population, there are many more vaccinations to keep track of. In the elderly, there are a few that are important. Otherwise, you will usually see tetanus as a big one being asked in the ED regardless of the age. You basically want to know what vaccination and when/how long ago they had it.
7. Additional cancer screenings: There are a lot. For example, gynecologic screenings, breast screenings, colon cancer screenings, lung cancer screenings… you get my point. Each has a specific set of questions and age requirements. Usually your doctor will be the one to ask, you just need to put if they have or haven’t. If they have, what age the screening was done/how long ago and what the results were.

General Information for the plan

Yes, well exams tend to take a while simply because you need to have a thorough examination. And if you are just writing the note, it means more things for you to click/type out. However, not every well exam you do will be daunting. And neither will the note. Typically most people don’t have several complaints and are just there to get yearly bloodwork and a pat on the back. However, you will have people with a list of complaints/concerns and then you have a massive HPI and usually a larger plan.

But well exams aren’t just the large HPI’s. The plan is also important. General health information gets relayed here along with information for each complaint. Several of the complaints listed in the above section go over areas that need to be counseled on. You may end up discussing a lot of this or majority of this information. When one of your providers frequently has a spiel about something, I suggesting making a “dot phrase” or quick phrase. That way, you can just pull it into the note and you don’t have to re-type it all the time.

Additional things:

• Counseling on diet and exercise.
• Exercise prescriptions
• RICE instructions
• how to measure your blood pressure
• low salt diet
• screenings
• home safety
• General discussion about labwork/imaging
• general discussion about what to return for/call/go to the emergency department for

Again, depending on the encounter will depend on what is brought up. Once you see a few you will start to get the hang of it. As a scribe, if you can’t pick up well and run with it you won’t make it very far. As a medical student, PA student, or nursing student, you should have enough background to trigger this knowledge to help you run with it. That is what you are being trained to do after all!

Anywho, good luck and cheers!