The document outlines the crucial role of medical scribes in recording patient information and managing medical records, emphasizing the legal implications and structured format (subjective, objective, assessment, plan) required for documentation. It details the subjective section including the chief complaint, history of present illness, and relevant medical histories, as well as the objective section covering physical exams and medical decision-making. Furthermore, it categorizes patient visits into different levels based on care complexity, which informs the documentation and management of cases.

1. The Medical Scribe’s
Role

2.  The medical record is an important part of
the patient’s care in the clinic or
emergency room.
 The information a scribe records on the
chart could affect how the patient is
managed currently or in the future.

3.  To communicate relevant information to
other medical personnel.
 It is a legal document that can be
presented in a court of law.

4. A physician may be asked to testify in
cases of:
◦ Rape
◦ Homicide
◦ Assault
◦ Child abuse
◦ Civil procedures involving personal injury

5.  The method used in charting the patient’s
stay through the clinic/ED must follow a
logical progression.
 The most common method is to consider
the chart to have four generalized
sections:
◦ Subjective
◦ Objective
◦ Assessment
◦ Plan

6.  The Subjective portion includes:
◦ Chief Complaint (CC)
◦ History of Present Illness (HPI)
◦ Review of Systems (ROS)
◦ Past Medical History (PMHx)
◦ Family History (FHx)
◦ Social History (SHx)

7.  The Subjective section pertains to any
information that the patient and/or family
states.
 This information is dependent upon the
patient’s condition, beliefs, personality, etc.
 This section will contain the patient’s story
in his/her own words.

8.  Chief Complaint
◦ The main reason the patient has come to
the clinic/ED.
◦ Every chart must have a Chief
Complaint.
◦ A short statement in the first sentence of
the HPI identifying why the patient has
come to the clinic/ED.
◦ Should be in the patient’s own words (if
possible).

9.  History of Present Illness (HPI)
◦ Explains the Chief Complaint.
◦ Describes why the patient is in the
clinic/ED and lists any pertinent positives
and negatives.
◦ This should be in a narrative paragraph
consisting of 4-5 sentences depending
on the severity of the patient’s condition.
◦ The HPI is a chronological description of
the development of the patient’s present
illness from the first sign/symptom or
from the previous encounter to the

10.  8 dimensions of HPI - directly related to
Chief Complaint
◦ Location
◦ Quality
◦ Severity
◦ Duration
◦ Timing
◦ Context
◦ Modifying factors
◦ Associated signs and symptoms

11.  Location
◦ A place on the body
 Examples: R flank, midsternal chest, etc.
 Quality
◦ Description of the complaint
 Constant, dull, crampy, intermittent, etc.
 Severity
◦ How bad is it?
◦ Usually on a scale of 1 to 10
 Examples: Acute, mild/moderate/severe, 7/10, 3
pads in the last hour, etc.

12.  Duration
◦ How long do the episodes last?
 Examples: 30 seconds each, 5 years, etc.
 Timing
◦ When did it start?
 Examples: 3:00 AM, this afternoon, etc.
 Context
◦ What were you doing when it happened?
 Examples: Running laps, just ate 7
doughnuts, awoken from sleep, etc.

13.  Modifying factors
◦ What makes it better or worse?
 Examples: Worse with activity, improve
with nitroglycerin, increased pain with
movement.
 Associated signs and symptoms
◦ Any other symptoms
 Examples: If CC is chest
pain, associated with diaphoresis and
N/V.

14.  A review of the patient’s past medical,
social history, and family medical history.
 Depending on the circumstances or
encounter, the patient’s Chief Complaint
could be an indication of a complication of,
or a result of, a preexisting condition or the
patient’s past medical history.

15.  Past Medical History (PMHx)
◦ Includes injuries, chronic illnesses, and
surgeries.
 Social History (SHx)
◦ Identifies behavioral risks such as
tobacco alcohol, or drug use.
 Family History (FHx)
◦ Includes relevant past family medical
information.

16.  Past Medical History (PMHx)
◦ Hypertension (HTN), coronary artery disease
(CAD), chronic obstructive pulmonary disease
(COPD), diabetes (DM), coronary artery bypass graft
(CABG), cancer (Ca).
 Past Surgical History
◦ A subcategory under PMHx.
 Social History (SHx)
◦ Tobacco use (Tob), alcohol use (EtOH), intravenous
drug use (IVDA), living situation (lives alone, lives with
others, nursing home, or lives at home with parents).
 Family History (FHx)
◦ Includes genetic traits, DM, Ca, cardiac disease, etc.

17. Common ROS:
◦ General
◦ Eyes
◦ ENT
◦ CVS
◦ Resp
◦ GI
◦ GU
Review of Systems
(ROS)
Identifies any recent
symptoms the
patient may have
other than the
current illness.

18. A Review of Systems is an inventory of
body systems obtained through a series of
questions seeking to identify signs and/or
symptoms which the patient may be
experiencing or has experienced.

19.  General Symptoms
◦ e.g. diaphoresis, cold symptoms, fever, chills.
 Eyes
◦ e.g. Visual changes, blindness, ophthalmoplegia, blurry, eye
pain, discharge.
 Ear, Nose, Throat, Mouth
◦ e.g. dysphagia, tinnitus, epistaxis, rhinorrhea.
 Cardiovascular
◦ e.g. palpitations, edema, cyanosis, dyspnea on exertion, CP.
 Respiratory
◦ e.g. SOB/dyspnea, wheezing, cough.
 Gastrointestinal
◦ e.g. dysmenorrhea, dyspareunia, dysuria, vaginal bleeding.
 Musculoskeletal
◦ e.g. arthralgia, myalgia.

20.  Skin/Breast
◦ e.g. rashes, hives, discoloration, pallor,
mastectomy.
 Neurological
◦ e.g. H/A, dizziness, LOC, numbness,
paresthesia.
 Psychiatric
◦ e.g. suicidal, depressed.
 Endocrine
◦ e.g. cold intolerance, heat intolerance,
polydipsia, polyuria.

21.  EXCEPTIONS:
◦ If a patient is unable to provide any information
due to severity of illness, inebriation, intubation,
unconscious, etc., you may check the “Unable to
obtain HPI/ROS/PMFHSH secondary to pt’s
condition.
◦ Be careful when using this caveat, and only use it
if it really applies (HPI, Past Medical/Social/Family
History, and ROS only).
◦ Ask the physician for clarification when needed.
◦ Speaking another language is not an exception.
◦ Physical exam must be documented.

22.  The Objective portion includes:
◦Physical Exam
◦Medical Decision-Making
Elements

23. The Objective section contains
information that is obtained through
observation and testing and is
independent of an individual’s
interpretation.

24.  Physical Examination (PEx)
◦ Information is more medically-oriented
◦ Information elicited through observation,
palpitation, percussion, and auscultation.
 Medical Decision Making (MDM)
◦ Documented under “Progress Notes” and
contains Differential Diagnosis, Progress
notes, attending note.

25.  Differential Diagnosis (DDx)
◦ Lists the different conditions that testing
will rule out.
 Progress Notes
◦ Any new subjective information provided
by the patient and any new or changed
findings upon reexamination of the
patient.

26.  Example:
Re-eval at 1532 – Pt states she is improved. Nausea resolved. PEx: Abd
soft, NT/ND, nl active BS. Pt will be discharged and f/u with PMD advised
within 24 hours.

27.  Attending Note
◦ Recorded when a physician oversees a
resident case.
◦ This will follow the SOAP format.
◦ Example:
A) Attending Note: Reviewed and agree c Hx.
B) PEx – GI: abd soft, NT, CVS: RRR s MGR. RESP: Lungs CTA.
C) A: UTI vs. Kidney stone
D) P: Labs, CT abd/pelvis r/o stone

28.  The Assessment
portion includes:
◦ Diagnosis:
 The physician’s
impression of
the patient after
combining the
information in
both the
Subjective &

29.  The Plan consists of:
◦ How the physician manages the patient’s
care after the final diagnosis has been
identified and can include:
 Admission
◦ Ensure that the chart has been coded to
the appropriate level and enter
admission information.
 Discharge Instructions
◦ Lists the various treatments, medications

30.  Level 1: Visits requiring very minor care.
This level is seldom used in the ED but
would be used in a clinic setting.
◦ Removal of sutures from a well-healed, uncomplicated laceration.
◦ Tetanus toxoid immunization; Depo-Provera injection; hormone
injections.
◦ Several uncomplicated insect bites.
 Level 2: Diagnosis reached without the aid
of any labs or x-rays.
◦ Painful sunburn with blister formation on the back in an otherwise
healthy patient.
◦ Child presenting with impetigo localized to the face.
◦ Minor traumatic injury of an extremity with localized pain, swelling,
and bruising.
◦ Red, swollen cystic lesion on patient’s back in an otherwise
healthy patient.

31.  Level 3: Visits requiring minor lab work such as
CBC, U/A, or a few x-rays.
◦ Well-appearing child who has a fever, diarrhea, and
abdominal cramps and is tolerating oral fluid.
◦ Inversion ankle injury, patient is unable to bear weight on
the injured foot and ankle.
◦ Acute pain associated with a suspected foreign body in the
painful eye.
◦ Blunt head injury with local swelling and bruising without
subsequent confusion, loss of consciousness, or memory
deficit in an otherwise young and healthy adult.
 Level 4: Visits requiring extensive lab workup or CT
scan.
◦ Child sustaining a head injury (falling off bicycle) with brief
loss of consciousness.

32.  Level 5: Visits requiring admission into the
hospital, critical care patients.
◦ Complicated overdose requiring aggressive management to
prevent side effects from the ingested materials.
◦ New onset of palpitations/tachycardia requiring IV drugs.
◦ Active upper gastrointestinal bleeding.
◦ Motor vehicle accident with intraabdominal injuries or
multiple extremity injuries.
◦ Acute onset of chest pain compatible with symptoms of
cardiac ischemia and/or pulmonary embolus.
◦ Sudden onset of “the worst headache of my life” with
associated meningismus, nausea, and vomiting.
◦ New onset of a cerebral vascular accident.
◦ Acute febrile illness in an adult, associated with shortness of
breath and an altered level of alertness.

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