H&P Assessment Tool: Tell me your IDEAs

WRITTEN HISTORY

Detailed HPI

Defined as including a complete description of the complaint(s) such as location, quality, severity, duration, timing, radiation, factors that aggravate or alleviate symptoms

minimal to none                              some to many elements                                most or all elements

Descriptive HPI

Defined by use of semantic and descriptive vocabulary such as acute or chronic, sharp or dull, continuous or intermittent

minimal to none                              some to many elements                                most or all elements

Chronologic HPI

Defined as telling a clear story that flows logically

minimal to none                              some to many elements                                most or all elements

Contextualized HPI

Defined by identification and inclusion of key findings from past, family, and social history and relevant other symptoms that might otherwise belong in later portions of the comprehensive history.

minimal to none                              some to many elements                                most or all elements

Complete comprehensive history

Defined as a complete past, family, and social histories and complete ROS

minimal to none                              some to many elements                                most or all elements

WRITTEN PYSICAL EXAMINATION FINDINGS

Complete physical examination

Defined as documenting a comprehensive examination

minimal to none                              some to many elements                                most or all elements

Key physical examination findings

Defined as including an exam that highlights the absence and presence of the key exam findings as suggested by the diagnostic possibilities

minimal to none                              some to many elements                                most or all elements

WRITTEN ASSESSMNENT

Interpretative summary

Defined as providing a concise summary statement that uses semantic vocabulary to highlight the most important elements from the history, exam, and testing and to interpret and represent the patient’s main problem.

minimal to none                              some to many elements                                most or all elements

Differential diagnosis

Defined as offering more than one relevant diagnostic possibility, committing to what is most likely and considering what is less likely or unlikely yet important to consider.

minimal to none                              some to many elements                                most or all elements

Explained well

Defined as explaining the reasoning behind alternative diagnoses including the epidemiology and key features and how these compare/contrast with the patient’s presentation and the lead diagnosis.

minimal to none                              some to many elements                                most or all elements

Alternative well considered

Defined as explaining the reasoning behind alternative diagnoses including the epidemiology and key feature and how these compare/contrast with the patient’s presentation and the lead diagnosis.

minimal to none                              some to many elements                                most or all elements

WRITTEN PLAN

Well-reasoned plan

Defined as including reasons for diagnostic testing and treatments and summarizing the evidence to support decisions.

minimal to none                              some to many elements                                most or all elements