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Intro To Clincial Inquiry Flashcards

1
Q

What is the purpose of documentation?

A
  1. Memory aid
  2. Communication
  3. Quality assessment and research
  4. Administrative and legal matters
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2
Q

How to document when there is no EMR?

A
  1. Use permanent ink
  2. All entries should be noted by date and time
  3. Include your signature
  4. Never alter an entry
  5. No blank lines between entries
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3
Q

What should you do if you have omitted data?

A

If something is omitted do NOT add the information
*make a separate entry (addendum)
*on the addendum include the date, time, initials

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4
Q

How to correct a mistake when there is no EMR?

A
  1. Draw a single line through the error
  2. Label as an error
  3. The error, correction, and addendum should be initialed with time and date of the correction
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5
Q

When to conduct a “Complete History and Physical”

A

When a person presents as a new patient to a practice setting

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6
Q

What are the multiple reasons to conduct a “Complete History and Physical”

A
  1. Pre-op physical
  2. Annual physical
  3. Wellness exam
  4. Medicare Annual
  5. Pre-participation sports physical
  6. Pediatric Well Child Check (WCC)
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7
Q

What is a Pre-op appointment? (Comprehensive H&P)

A

Patient needs clearance from clinician for surgery
-Ensure surgical team is aware of al health conditions and okay for surgery

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8
Q

What happens during an Annual exam? (Comprehensive H&P)

A

The patient is overall healthy and comes in once a year for a visit

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9
Q

What happens during a wellness exam? (Comprehensive H&P)

A

The focus is the patients wellness, ensures all Health Promotion & Disease Prevention items are being address and up to date
*No problems or conditions are discussed or evaluated

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10
Q

What happens during a Medicare wellness appointment? (Comprehensive H&P)

A

The focus is wellness but if the patient has concerns they ARE able to address and bill

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11
Q

What happens during a Pre-Participation sports physical? (Comprehensive H&P)

A

Identify and risk factors that would impact students athletes ability to safely play sports

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12
Q

What happens during a Well Child Check? (Comprehensive H&P)

A
  1. Developmental milestones
  2. Immunizations
  3. Birth history
  4. Concerns of parents
    5.Anticipatory guidance
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13
Q

What are the components of the Complete H&P?

A
  1. Comprehensive health history
  2. Complete physical exam
  3. Database of labs, radiologic and other studies
  4. Assessment
  5. Plan
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14
Q

Where does the database of labs go in a complete H&P?

A

ALWAYS in objective
*AFTER the physical examination documentation

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15
Q

What are the components of a complete history?

A
  1. Patient identifying information
  2. Source and reliability
  3. CC
  4. History of present illness
  5. Past Medical History
  6. Past Surgical History
  7. Medications
  8. Allergies
  9. Family History
  10. Social History
  11. ROS
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16
Q

What is the patient identifying information?

A
  1. Patient name (HIPAA)
  2. DOB
  3. Medical record number (HIPAA)
17
Q

What are some things for source and reliability of information?

A
  1. Patient, caregiver, chart, spouse
  2. Reliable?
18
Q

Where does the lab and diagnostic studies go?

A

After the physical exam
*only results that you have at the time

19
Q

Assessment is also consider what?

20
Q

When is a SOAP Note used?

A
  1. Used for an established patient
  2. Used to document a problem oriented complaint
21
Q

What is the “S” of SOAP

A

Subjective
1. What the patient tells you, in their own words
*historical information

22
Q

What is the “O” in SOAP note?

A

Objective
1. Physical exam findings and results of diagnostic tests
*Use medical terminology

23
Q

What is the “A” in SOAP?

A

Assessment
1. Your diagnosis
*May include differential diagnoses

24
Q

What is the “P” in SOAP?

A

Plan
1. Course of action

25
What are the components in the Subjective Data?
1. CC 2. History of present illness 3. Pertinent medications and allergies 4. Pertinent family history 5. Pertinent social history 6. Pertinent ROS 7. Pertinent PMH PSH
26
What does OLDCARTS stand for?
O: onset L: Location D: duration C: character A: Alleviating/ Aggravating R: radiation T: Temporal Pattern or Timing S: Symptoms or severity
27
What does OPQRST stand for?
O: Onset P: Palliative or provocative Q: Quality of pain R: Region affected or radiation S: Severity of pain T: Timing
28
What are pertinent positives? (Subjective)
1. Data that helps support or suggest one diagnosis more than another 2. Presence of symptoms
29
What are Pertinent negatives?
1. Absence of symptoms 2. Eliminates diagnosis 3. Helps rule out other diagnosis
30
What to include in the “Objective” part of the SOAP Note
1. What you see or observe first hand 2. Heading Format 3. Include pertinent positive and negatives
31
What is the Objective format of a SOAP note?
1. Vital signs and general assessment 2. Focused physical exam 3. Procedure notes 4. Pertinent laboratory or diagnostic results
32
What is the Assessment of a SOAP note?
1. The diagnosis *Subjective+Objective=assessment 2. Can use a presumptive diagnosis *symptom, complaint, condition, or problem
33
What does ICD-10-CM coding stand for?
International Classification of Diseases 10th edition clinical modification
34
What is the purpose of ICD-10-CM coding?
Used to determine the level of reimbursement for medical services
35
What is the Plan part of SOAP note?
1. Plan of care *Tests *Pharmaceutical *HPDP *Patient education *Follow-ups
36
How should the plan be written out to match the assessment portion?
1. Assessment 2. Assessment 1. Plan 2. Plan *Correlate the diagnosis with the same number in the plan
37
What does VINDICATES-P stand for? (Differential diagnosis)
V: Vascular and hematologic I: Inflammatory or infections N: Neoplastic or nutritional D: degenerative or deficiency I: Idiopathic, iatrogenic C: Congenital A: Autoimmune T: Traumatic E: Endocrine S: Specific organs P: Psychosomatic

Clinical Inquiry And Communication (8 decks)

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