I-human HPI and Management Plan template

CC (reason for encounter): brief subjective QUESTION. You will type this and the HPI in the EHR section of the case (NOT the problem statement).

HPI (History of present illness): It can only be graded from this place!  You will receive a zero for this section if not in the correct place.   

This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. This is for subjective findings. Use LOCATES or OLDCARTS Mnemonic to complete your HPI, but this is meant to help you develop the paragraph and should not be headings in a professional note. You need to start EVERY HPI with age, race, and gender (e.g., 14-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. Include any pertinent history information that might impact the differential diagnosis formulation. If the CC was “headache,” the LOCATES for the HPI would include the following information: 

Onset: 3 days ago 

Location: head 

Duration: Lasts for an hour or two

Character: pounding, pressure around the eyes and temples 

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia 

Relieving factors/Exacerbating factors: light bothers eyes, Aleve makes it tolerable but not completely better 

Timing: after being on the computer all day at work 

Severity: 7/10 pain scale 

Management Plan Templatemust include these headings: This section is worth 70 points.

1. Problem Statement 5 pts 

Problem statement should include:

a. CC

b. Key subjective findings (symptoms)

c. Key objective findings (PE)

2. Primary Diagnosis, Differentials & Coding—10 points (all areas must be addressed)

a. What is the primary dx ICD-10 code (1 point):

b. What is your rationale for arriving at this primary diagnosis? You must integrate the pertinent finding and support your rationale with evidence-based literature (resources) (4 points)

c. Include CPT codes, and any procedural codes (such as nurse lab draws, vaccinations given, biopsies) (2 points):

d. Differential diagnoses (ddx)with rationale and resources. Minimum of 3-5 differentials (primary dx does not count as a differential). For well-child visit, if there are no other health issues, then differentials are not needed. (3 points)

i. DDx#1-

ii. DDx#2-

iii. DDX #3-

3. Medications: (10 points)- Must be written as a prescription.

For example:

Med: Amoxicillin 400mg/5ml, 5 tsp po BID x 10days

4. Treatment plan / SDOH / Health Promotion 20 pts

a. Treatment plans-should be supported by clinical guidelines.  Should include non-pharmacological interventions. (10 points)

b. SDOH: address all 6 areas of social determinants of health (5 points)

c. Health Promotion/Anticipatory guidance: (5 points)

Must list a minimum of 5 age appropriate. Do not simply write f/u on vaccinations, be specific. Use your Bright Futures to help you with this area.

5. Pt. education (10 points)- – Educate parent and patient about today’s visit/diagnosis/meds etc. Must list a minimum of 5 patient education regarding today’s visit.

6. Follow up- 10 pts

a. Timing/when: (2 points)

b. Instructions: (4 points)

c. Symptom to watch for that will prompt a return (red flags): (4 points)

7. References 5 pts

a. *In text citations- (1 point)

b. *Min 3 evidence-based references  less than 5 y/old ( 3points)

c. *Clinical guidelines cited in treatment plan- ( 1 point)