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Different sources include different questions to be asked while conducting an HPI. Several acronyms have been developed to categorize the appropriate questions to include. The Centers for Medicare and Medicaid Services has published criteria for what constitutes a reimbursable HPI. A "brief HPI" constitutes one to three of these elements.
For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.
The Centers for Medicare and Medicaid Services [5] has published criteria for what constitutes a reimbursable PMH. A PMH is considered one of three elements of the "Past, Family, and Social History" (abbreviated as PFSH): [6]
The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting.
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
It is specifically adapted to elicit symptoms of a possible heart attack. [2] Each letter stands for an important line of questioning for the patient assessment . [ 3 ] [ 4 ] This is usually taken along with vital signs and the SAMPLE history and would usually be recorded by the person delivering the aid, such as in the "Subjective" portion of ...
The cardiovascular examination is a portion of the physical examination that involves evaluation of the cardiovascular system. The exact contents of the examination will vary depending on the presenting complaint but a complete examination will involve the heart (cardiac examination), lungs (pulmonary examination), belly (abdominal examination) and the blood vessels (peripheral vascular ...
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