___________ based on the patient's responses to questions posed by the clinician, the history describes the patient's personal sensation of the current health complaint, the status and function of the patient's body, as well as past medical history, genetic medical history, and/or any social habits, which may impact the patient's health.
Fill in the blank with correct word.
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Q. 2) ___________ narration of the circumstance or event that occurred prior or coincidentally with the onset of the patient's sign, symptom, or disease; circumstances may or may not be related to the sign or symptom
Fill in the blank with correct word.
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Q. 3) ___________ a measurable, objective indication of how the pain, discomfort, sign, or symptom has affected, or currently affects the patient's day-to-day life
Fill in the blank with correct word.
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Q. 4) ___________ any of eight standardized descriptions with which the patient may provide a visceral, personalized description of the specific health issue, complaint or disease for which the patient came to the clinician
Fill in the blank with correct word.
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Q. 5) _______ a report or observation of evidence of pathology or disease in their own physiology, such as blood in urine, and/or subjective observations of physical experience such as pain or discomfort
Fill in the blank with correct word.
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Q. 6) 1. How does documentation of the HPI improve the quality of medical documentation? How would the absence of HPI impact the medical documentation of an E/M service visit?
What will be an ideal response?
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Q. 7) Describe how you have personally experienced the history of present illness during an E/M service visit (a visit to the physician's office, the ER, accompanying a child or parent during a visit to the physician.) Did you describe the HPI, if so how? Have you experienced the absence of any HPI questions? How did this impact your experience of the E/M service visit?
What will be an ideal response?
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Q. 8) In your own words, explain how documentation of the HPI improves the documentation of the chief complaint. Is it important for physicians and clinicians to understand the history of present illness? Why or why not?
What will be an ideal response?
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Q. 9) Select one activity you perform every day, such as brushing your teeth, starting your car, feeding the dog/cat, scrambling eggs, etc. Then, document this daily activity following the documentation exercise 1.1. Be sure that, in your documentation, you do not utilize the phrase that reflects the activity you are documenting.
What will be an ideal response?
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Q. 10) Almost every person has participated in an evaluation and management services during their lives. Choose one evaluation and management service, such as an office clinic office, inpatient hospital stay, emergency department visit, and explain why complete and thorough medical documentation can improve the healthcare experience.
What will be an ideal response?
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