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HPI Template: General/Well exam

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:

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).
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.
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.
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.
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.
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.
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!

What’s In My Locker?

Hello MedHatters!

This week I wanted to share what I had kept in my locker as a first year. I will go over what was super useful (to me), what I would have replaced, and what I wish I would have had. Hopefully this helps guide you if you plan to use your locker as a first year student!

Now, I know most schools don’t have assigned lockers. On the KC campus, students have access to lockers that they can sign out. They need to bring their own locks and at the end of the year have to give up the locker. And once there are no more, you can’t get a locker. Since there are so many students on the KC campus (its not just medical students on that campus), getting a locker at any other time after the very beginning of the school year can be hard. At some schools you don’t have a designated space. In Joplin, we are a small enough campus that we all have designated lockers assigned to us. Each student is assigned one and encouraged to use it so our stuff isn’t all over the place. They come with locks and are given to you during orientation. It is yours for the first 2 years.

Currently, we have enough lockers that each club also gets a locker. So I have 2: my personal one and one for MAOPS (I’m on the board for this club). I’m sure once more students are on campus they will switch to not having club lockers. But I’m not sure how long that will take.

And no. Not everyone uses their locker. So don’t feel obligated to really use yours!

What I Had in My locker:

A blanket. I got a lot of flack for this at first. But you know what? It gets really cold on campus no matter what time of year it is. And I’m the type of person that is always cold (or gets cold easily). If I have to be here for class or to study, I want to be warm.
Lots of slipper socks. I have many pairs. It’s nice to keep my feet warm and I don’t have to wear shoes.
Gallon zipper bags. This was helpful for anatomy. Either to put my dirty/smelly scrubs in so it wouldn’t stink up my locker or to put my iPad in to take into lab with me! Definitely a must as a first year student for anatomy if you plan to bring your iPad into the lab.
Usually an anatomy atlas. I have Dr. Olinger’s pictured because it is easier to carry around, but I believe Netter’s stayed in my locker.
Spray/lotion. I would use this to help mask the awful dead body smell if I couldn’t go home and shower right away.
My “tool” bag. This had all the instruments that were “required” for first years. Honestly I did not need all of these… But I kept them in a bag in my locker since I needed to use most of them while on campus.

Not pictured: My otoscope & stethoscope. They are currently packed for my Kenya trip!

For the blanket and slipper socks, I would periodically take them home and wash them and bring them back. I did a lot of walking around in those socks while on campus and they did get dirty somewhat fast since I used them so often. But since I’ve dedicated those items to just use at school, its not like I was using them in my home. But don’t worry; they definitely were washed many times during the year!

What I had that I would Change:

I originally had my white coat in my locker. But turns out there wasn’t a ton of space for this. Also, I have a bottom locker. There were definitely times where I would hear people from top lockers spilling coffee, juice, energy drinks, etc and it would leak down to the bottom locker. Not a big deal most of the time, but I didn’t want that happening to my white coat.
I also originally had coffee pods in my locker. This is a great idea, except I got really cheap and nasty Walmart ones and turns out I didn’t really drink them because they were gross. Definitely recommend getting slightly better quality ones (we have 2 Keurigs on campus). OR some friends had instant coffee in their locker.
Sometimes I would put a spare change of clothes in my locker. I stopped doing that though simply because I live less than 5 minutes away from campus and could easily go home and shower or change and come back. For students who plan to spend longer days here, it may be a good idea to keep an extra pair of scrubs or extra clothes to change into.

What i wish i had:

Ibuprofen. Oh lord I needed this more often than I can remember. I would always tell myself to put some in my locker and then forget. Luckily there was always a classmate on campus that had a bottle of it.
Snacks. This is another one I wish I had. Sometimes I would just want something salty and snacky and wouldn’t have any. Some classmates had large bulk bins of snacks like this in their locker.

And that is basically it. Now, I spent a lot of time on campus. I mean A LOT. But if you aren’t one to really spend time on campus, then you probably don’t need to have this much stuff in your locker. E really only kept his tools/instruments in his locker. Sometimes he left his white coat. But really he just needed a place for his stuff during anatomy lab.

Bonus! What i kept in my car:

Yup, I went there.

I usually kept an extra jacket in my car. Mostly because I knew I would be cold during lectures or while studying even if it was balls hot outside. So I would just keep it in there to grab on my way into campus or if I needed to run out and grab it.

I also kept my Moore’s book in my car. Why? Well that thing is huge. And since we needed it for most anatomy courses (or at least parts of that book) I wanted to have it on hand. What if I needed it on campus and it was at home? What if I needed it at home and I kept it in my locker? You see my dilemma? So I kept it in my car. That way I could run out and grab it if I needed it.

Occasionally my blanket would hangout in my car if I would have it in class and didn’t want to drag it back into my locker before leaving. But those were the two main things that I kept in my car during first year.

Double bonus! what do i actually need for the instruments?

Now, I’m sure the school won’t be happy with me saying this. But like, you really don’t actually use all those tools. There will be third years who sell them at much cheaper but still somewhat pricy because most of those instruments are new.

Some people get much cheaper versions off of Amazon.

A lot of students just used other student’s stuff because they didn’t bother to buy it.

And then you have people like me that bought the tools but really didn’t use most of them (at least for first year).

Stethoscope: Yes. Yes you need this. You will use this the most. I had a cheaper one that an ex left me (he was an EMT for awhile) and I somewhat wish I would have gotten a slightly better one. But, I didn’t want to spend anymore money.
Reflex hammer: Yes you do use this. If you are going to buy this, get the rubber one, not the plastic one. I promise it will be less painful given the amount of times you practice taking reflexes with the rubber one. BUT! They do provide this one during your SP encounters. You may not be provided this during score 1 in second year though.
BP cuffs: Um, kinda. I know you need this more for second year for score 1. We needed it to practice on one another before our vital signs competency in first year and that is basically it. You get tested on the mannikins that have an attached BP cuff for this competency. So, you don’t all need to buy one since you are just using it for practice in first year. Also, all the rooms in Joplin have BP cuffs for your SP’s.
Otoscope: Honestly we just used this during one or two labs. We have attached ones in the SP rooms to use. Pretty sure you need it for second year though for score 1, but first year we didn’t do much with it.
Ophthalmoscope. Same thing. we just used it during labs. All the SP rooms have one in Joplin. Will likely need it for score 1 in second year.
Eye chart: Only used this during neuro lab and the first instrument lab in first year. They provided it during SP’s. Not sure if this is needed in second year? Will let you know.
Tuning fork: Same thing. Only used it during those 2 labs like the eye chart. It was provided during SP’s. Not sure if we need this in second year yet.
Otoscopy bulb: WE DID NOT USE THIS ONCE. Not at all. Really not sure why we needed to buy this. Maybe we will use it in score 1 but my god I’m not even sure we used it in the intro to instrument lab.

And I think that’s it for the instruments. A lot of what is on your list you will be expected to have for score 1 in second year (like I keep repeating). Even then, I’m not sure how much you will use. But sometimes when you do mass clinics like that you aren’t all doing it at the same time. So you may get away with just borrowing each other’s stuff OR borrowing from a first year below you.

So, you decide if it is worth buying all of this in your first year. You may get away with not needing it much and can borrow from other students. By the time you get to 3rd and 4th year, all of this will be provided by your clinics.

Hope this was helpful. Cheers!