chillingpanda

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What are you thought process when writing up an HPI? Do you just jot down the CC and write the symptoms, history, and stuff afterwards? I've been shadowing for a week now at an orthopedic clinic with another scribe and I kinda got the basics down, but I might be starting to actually work with the EMR this week and I don't want to be completely suck at it.
 
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chief complaint followed by onset, location, duration, alleviating/exacerbating factors, associated symptoms, radiation, etc. Then stuff about their history that might contribute to their chief complaint. Then social history stuff like smoker, drugs, alcohol.
 
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chief complaint followed by onset, location, duration, alleviating/exacerbating factors, associated symptoms, radiation, etc. Then stuff about their history that might contribute to their chief complaint. Then social history stuff like smoker, drugs, alcohol.
And don't worry if you don't have some of it, most patients do not mention or know half this crap.
 
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LA-2017

I scribe in an emergency room. My first sentence is the primary complaint and the onset. My second sentence is usually something of importance such as hx of heart attack 3 months ago, allergic to _____, or last visit for this complaint. After that I describe the history of the complaint. Then I note things that are less relevant to the primary complaint such as denies _____ or requests a psych consult.
 
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The_Bird

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Primary complaint -- time of onset -- severity if applicable

Hx of hospitalization, surgery, physical alterations -- date

Hx and family Hx of long-term illness and treatments/medications currently and previously taken and/or prescribed
 
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Horse Apiece

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Depends if you have dot phrases to work with in EPIC which are super helpful, but start with:
Patient age, sex (can insert revelant history here or at end of HPI) (pregnancy with correct abbreviations g3p2, etc) chief complaint (some docs want only one, others are ok if patient has two-ish associated things). Potentially who brought them in if they are young or mentally/physically disabled, or if brought by EMS will indicate here and interventions done en route (less relevant in clinic). Recent medically treatment relevant to symptoms here in one to two sentences (eg. seen in clinic by PCP for *** with labs/imaging done, which were negative/***, diagnosed with ***, started on cipro on DATE and has been compliant with plan of care to point, etc.). If recent surgery or procedure: s/p *** with Dr. *** on ***, no complications until ***. If these things arent relevant and this is the first point of care then just go over the story: Billy fell down the stairs earlier today (if time given include). Secondary to the fall Billy has right foot pain, but has been ambulatory and did not lose consciousness. Billy has had 4x instances of emesis since then. Pain rated /10 or on FACES scale if young, (modification of pain here). Patient (or parent/caregiver) denies ***these symptoms***. Has taken *** at home for ***(pain, nausea,etc), with *** relief of ***. (this is another spot to put relevant medical history here). No other alleviating or aggravating factors.

Depending on doctor some have easy ROS's: 10 systems reviewed no findings unless otherwise stated above, or you might have to put them out, eg. right foot pain, emesis, no loss consciousness.

Really you can write these in your sleep once you get going, and will learn what to include/not include also what is relevant from the records. I've tried to include some things to help here in a really general way, there is alot to learn, and my main recommendation is to look what terminology and phrasing the doctors use and adapt to USE THOSE CORRECTLY. Good luck and have fun.
 
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chillingpanda

chillingpanda

2+ Year Member
May 19, 2015
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Medical Student
Depends if you have dot phrases to work with in EPIC which are super helpful, but start with:
Patient age, sex (can insert revelant history here or at end of HPI) (pregnancy with correct abbreviations g3p2, etc) chief complaint (some docs want only one, others are ok if patient has two-ish associated things). Potentially who brought them in if they are young or mentally/physically disabled, or if brought by EMS will indicate here and interventions done en route (less relevant in clinic). Recent medically treatment relevant to symptoms here in one to two sentences (eg. seen in clinic by PCP for *** with labs/imaging done, which were negative/***, diagnosed with ***, started on cipro on DATE and has been compliant with plan of care to point, etc.). If recent surgery or procedure: s/p *** with Dr. *** on ***, no complications until ***. If these things arent relevant and this is the first point of care then just go over the story: Billy fell down the stairs earlier today (if time given include). Secondary to the fall Billy has right foot pain, but has been ambulatory and did not lose consciousness. Billy has had 4x instances of emesis since then. Pain rated /10 or on FACES scale if young, (modification of pain here). Patient (or parent/caregiver) denies ***these symptoms***. Has taken *** at home for ***(pain, nausea,etc), with *** relief of ***. (this is another spot to put relevant medical history here). No other alleviating or aggravating factors.

Depending on doctor some have easy ROS's: 10 systems reviewed no findings unless otherwise stated above, or you might have to put them out, eg. right foot pain, emesis, no loss consciousness.

Really you can write these in your sleep once you get going, and will learn what to include/not include also what is relevant from the records. I've tried to include some things to help here in a really general way, there is alot to learn, and my main recommendation is to look what terminology and phrasing the doctors use and adapt to USE THOSE CORRECTLY. Good luck and have fun.
What medical terminology do you usually use? Just asking because we weren't given a packet or anything to study and I guess we would learn as we go, but I feel like I should at least know some orthopedic ones, right? Unless if the doctor usually just uses the medical terminology as he's talking to the patient and you just type whatever he says?
 

Horse Apiece

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That is a very broad question, but I mainly worked in the ER so pretty much everything under the sun. I would make a note of everything new during a shift or of a phrase a doc used that I would like to use in the future and still have those sheets somewhere, but didn't really refer back to them ever. Google things you don't know. I was thinking more of phrasing for the HPI, because it is Doc dependent for how they would like things done. You'll learn onsite, don't worry, the difference between a good and a bad scribe is that the bad scribe stops learning and improving. Just do your best every shift and try to keep getting better.
 
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liquidsodium

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Jul 18, 2016
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Many of the things you'll learn as a scribe will be learned through experience and time. You can try to follow a general format as several people have provided above, but you'll eventually need to become flexible with shifting that format to include notable details, chart reviews and prior workups relevant to the patient's chief complaint. Ultimately, you want to present a comprehensive narrative of the events leading to the patient's presentation. It'll help you hugely to familiarize yourself with the differential diagnoses associated with the most common ortho CCs, since your goal is really to guide the reader through the CC and the details pushing for/against a particular diagnosis. Read more about the most common ortho conditions and methods of evaluation/management (you'll see these referenced while working and then Google to read further) and don't be afraid to ask questions. I hope you don't see yourself as a "typewriter" and really take the time to think critically and learn from the experience. After about a year, my main internal med doc and I work very much as an (almost) equal team on our patients, which makes my scribe job especially rewarding. Make the most of it while you can!
 
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chillingpanda

chillingpanda

2+ Year Member
May 19, 2015
163
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Status
Medical Student
Many of the things you'll learn as a scribe will be learned through experience and time. You can try to follow a general format as several people have provided above, but you'll eventually need to become flexible with shifting that format to include notable details, chart reviews and prior workups relevant to the patient's chief complaint. Ultimately, you want to present a comprehensive narrative of the events leading to the patient's presentation. It'll help you hugely to familiarize yourself with the differential diagnoses associated with the most common ortho CCs, since your goal is really to guide the reader through the CC and the details pushing for/against a particular diagnosis. Read more about the most common ortho conditions and methods of evaluation/management (you'll see these referenced while working and then Google to read further) and don't be afraid to ask questions. I hope you don't see yourself as a "typewriter" and really take the time to think critically and learn from the experience. After about a year, my main internal med doc and I work very much as an (almost) equal team on our patients, which makes my scribe job especially rewarding. Make the most of it while you can!
So basically I shouldn't worry about the medical terminology? When I was shadowing the scribe the first week, I didn't really see her type anything that the doctor didn't already say.