6011 Overview Flashcards
Patient History
Reliable tool for Dx. // 70 - 90% of Dx defined by history alone
Why is history important?
When paired with proper assessment technique and clinical reasoning - ensures quality, efficient, lower cost care
SOAP
S = Subjective = what patient Says (CC in patient’s words)
O = Objective = what you see (VS & Exam Findings & any results at time of visit, such as Accucheck or x-ray during visit)
A = Assessment (Impression / Diagnosis)
P = Plan
(E) Evaluation = How do you know if your plan worked?
Organize SOAP Note
Subjective information first. Name, Age, Ethnicity, CC
Chief Complaint (CC) History of Present Illness(HPI) - informs review of systems Past Medical History Family and Psychosocial History Review of Systems
“Throwing up for 3 weeks”
“Blurry vision” - patients words
Objective = vital signs, physical exam
“Pupils equal, reactive to light”
Importance of SOAP Note
Taking information from a patient and organizing it
Avoid: subjective or evaluating terms (“patient was rude” / “patient is combative”)
Make sure everything you write is OBJECTIVE. Don’t have anything in here that can hurt a patient’s feelings.
Documentation
Do not use diagnoses in findings –> Do not say “conjunctivitis” // conjunctive is red, errythemmis, etc
Your First Patient
Assessment starts when you wake up - starts when you look around at the environment. Think about your community and your resources
Step 1 - chart review
Start to narrow down risks (woman - pregnant?)
Trends - big picture (blood sugar 500 –> 300)
S - identifying info. Includes name / age / gender / occupation / interpreter? / who is providing information / referred by whom / reliability (“details of illness are confusing” - try to make comment as objective as possible)
Chief Complaint
In patient’s own words
This is NOT a diagnosis. Do not use “follow up” or “fracture of an ankle”
CC on intake may be different than what patient reveals to PCP
HPI (Also in “S” - part of what doctor Says)
MUST INCLUDE: location / quality / severity / duration & timing / context / modifying factors / associated signs and symptoms (7)
Context - “after I eat”
Associated S&S - visual changes with headache
HPI for chronic disease
DM / COPD
How is patient managing his/her problem. Think of systems that relate (eyes, nerve pain)
7 Dimensions of HPI
Location Quality Severity Duration & Timing Context Modifying factors Associated signs & symptoms
What is important about the interview?
Align your direction
Past Medical History
Depends on presentation (complete visits vs. episodic)
Include medications - and WHY patient is on this medication (Albuterol, asthma)
Note allergy and what allergy causes! (PCN causes rash)
Family History
1st degree blood relatives: siblings, parents
Anyone die of a heart attack before age 50?
Psychosocial History
“Take me through a day” / violence, work schedule, what they eat, exercise?
