Exam 2 Flashcards
(23 cards)
Complete SOAP template
CC, HPI, active medical problems, PMH, allergies, meds, family hx, social hx, ROS, assessment (medical diagnosis), plan (diagnostics, therapeutics, pt education, f/u, referrals)
What is a comprehensive visit?
Requires provider to collect all elements of hx and complete an age-appropriate physical exam to arrive at an appropriate diagnosis and POC.
What are common reasons for a comprehensive visit?
Establishing care, preventative care, employment physical, etc
What is an episodic visit?
Focused visit. Provider only collects data that they feel is appropriate to evaluate the concern the pt has presented with to determine a diagnosis and POC.
Common reasons for an episodic visit?
A specific concern such as pain or f/u on an established diagnosis (ex. HTN)
What is subjective data?
It is what the pt says (imagine the provider has their eyes closed with their hands in their pockets), the only data is ONLY what the pt says
What is objective data?
When the provider opens their eyes and takes their hands out of their pockets. This is when they observe/inspect, palpate, percuss, or auscultate. Can also include diagnostic results or clinical/screening tools utilizing objective data.
What is the purpose for the SOAP framework?
To order the visit (first gather hx- S, then completing an exam - O, then sitting down with the patient to discuss the diagnosis - A, then collaborating with the patient/family on a plan of care - P.
It is how we can communicate with others on the healthcare team via documentation and verbal report.
This is how we think through data to generate a hypothesis, then think through subjective data putting it into buckets to help us make a decision to let it go or do we keep it to go explore in the physical exam.
What are the sub-sections of history?
CC (“reason they are there”)
HPI (their story of their CC)
Active medical problems (conditions that are diagnosed and actively being treated for)
PMH (any past medical problems which have been resolved; women’s health should ALWAYS be included for women of childbearing age)
Medications (name, dose, frequency)
Allergies (meds, food, animals, environmental/latex)
Immunizations
Family hx (age, issues cause of death for 3 generations - for comprehensive)
Social hx (education, family, household, personal habits, interests, employment)
ROS (all systems for comprehensive, targeted for episodic)
What is a symptom analysis and where is it documented?
This is documented in the HPI, this is details of the CC gathered and analyzed
What is BOLDCARTS+1?
B: backstory (health just before onset of symptoms)
O: onset (when did it start)
L: location (where is the problem)
D: duration (how long has it been going on)
C: character (what is it like, description)
A: alleviating/associated/aggravating (what makes it worse/better, how has it progressed)
R: radiating (where goes it go/travel to?)
T: timing (when does it occur, under what circumstances, how often, time of day)
S: severity (scale of 0-10, impact on life)
+1: patients thoughts (what does the pt think might be the cause)
What is a significant positive?
Something we expect to find and DO find.
This increases or argues in favor of a specific hypothesis or diagnosis.
What is a significant negative?
Something we don’t find and DO NOT find.
This increases or argues in favor of a specific hypothesis or diagnosis.
What is confounding data?
Either something a provider DOES find and don’t expect to find, or something a provider DOES NOT find and expects to find.
They are pieces of data that argues against or makes the provider think there is something else going on.
Why do providers use screening tools, scales, and inventories for data collection?
They help to collect “good”/valid information in a short time. Quantifying data helps the provider see the problem more objectively. It minimizes clinician bias from questions. It is also cost-effective.
What is a symptom?
Result of having a disease
(ex. patient has strep and they have a sore throat/fever)
What is a risk factor?
Something that increases the incidence but does not directly cause it
(ex. living in a crowded situation can make someone more likely to get strep)
What is anchoring bias, and what is an example?
First impression
Excessive weight on one clinical feature that the provider typically leans on early in the patient encounter. This typically causes the clinician to stop thinking about alternatives, and once the decision is made, it is hard for the provider to change course
What is confirmation bias, and what is an example?
Following hunches.
Information that confirms the presumed diagnosis is accepted, and information that argues against it is dismissed. This type of bias typically leads to the correct diagnosis being missed entirely or wasting time.
What is momentum bias, and what is an example?
Continuing with suggested diagnosis.
Clinican prematurely accepts a diagnosis previously given to the patient without reaching their own diagnosis.
What were the screening tools used in Betty Braxton’s interview?
PHQ-9: screening tool for depression
ESS (Epworth Sleepiness Scale): used for OSA
What are the 3Es from SAMHSA?
Individual trauma results from an EVENT, series of events, or set of circumstances that is EXPERIENCED by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse EFFECTS on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.
What are the assumptions of trauma-informed care?
The 4 Rs
REALIZE the widespread impact of trauma
RECOGNIZING the signs and symptoms of trauma
RESPONDING fully and integrating knowledge of trauma into policies, procedures, and practice
RESIST RE-TRAUMATIZATION
