Health History Part 2 Flashcards
After performing the history and physical examination, the healthcare practitioner must:
Organize. Synthesize. Record the data. Record the problems identified. Record diagnostic evaluation. Record the plan of care
The patient’s record is a
legal document.
Court and other legal proceedings
Insurance payment determinations
Document the gathered data
legibly, accurately.
When using EMR, update information
Medication reconciliation
Allergies and immunizations
Interim hospitalizations or surgeries
General Guidelines
Take brief notes during examination.
Document as soon as possible after examination.
Make a concise outline.
Document observations and what patient tells you, not your interpretations
Types of Histories
Complete History
Inventory History
Problem (or focused history)
Interim History
Complete History and PE components
CC HPI (OLDCARTS) Past Medical History (PMH)/Past Surgical History (PSH) Family History (FH) Habits: nutrition, exercise, stress level, sleep pattern, caffeine intake, alcohol intake, cigarette smoking, illegal drugs Safety and Environmental exposures Medications Allergies Personal history Social history Review of Systems (ROS)
Physical Examination - Components
General statement Mental status Skin Head Eyes, ears, and nose Throat and mouth Neck Chest and lungs Breasts Heart and blood vessels Abdomen Male genitalia Female genitalia Anus and rectum Lymphatics Musculoskeletal Neurologic
Problem-Oriented - Components
The chief complaint (CC)
History of present illness (HPI)
Any treatment tried in the past (whether or not it was effective) and any pertinent Past medical history (PMH) and social history (SH)
Pertinent to the presenting problem, any:
Past Medical History (PMH)/Past Surgical History (PSH)
Family History (FH)
Habits, Safety and Environmental exposures
Medications/ Allergies, personal social history
Review of Systems (ROS)
Problem-Oriented PE
Any pertinent positive or negative exam
Only exam system persistent to the subjective information
A problem may be related to any of the following:
A firmly established diagnosis
New symptom or physical finding of unknown etiology or significance
New findings revealed by laboratory tests
Personal or social difficulties
Risk factors for serious conditions
Factors crucial to remember long term
SOAP
Subjective Objective Assessment Plan Acute SOAP note Chronic SOAP note
Subjective data
Information the patients tells you verbatim
Objective data
Inspection, palpation, auscultation, and percussion
The assessment section is composed of
Your interpretations and conclusions Diagnostic strategy Present and anticipated problems Needs of ongoing as well as future care What you think
