1. affect patient outcome 2. touch patients 3. handle bodily fluids or specimens 4. sign or authenticate 5. give verbal orders / submit EMR

``` check-in physician eval orders & results A & P check-out ```

A. H&P (history and physical): 1. HPI (history of present illness) 2. ROS (review of systems) 3. PE (physical exam) B. All possible explanations (differential Dx)

Lecture 1 Flashcards by Kristy Behrs

subjective

feeling

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objective

fact

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pain

patient’s feeling

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tenderness

physician’s assessment

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baseline

normal individual’s state of being

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auscultation

stethoscope listening

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inpatient

admitted to hospital

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outpatient

no overnight stay, short visit

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chief complaint

main reason for patient’s visit

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meaningful use

a set of govt. mandated criteria - must be obtained for every patient

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mid-level provider

LNP (NP), PA – works under supervision

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nurse / MA

records medical histories, symptoms, monitors patient, completes meaningful use req., administers meds, assists with procedures

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receptionist

answers phones, schedules, answers questions, check out, paperwork

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scribe

documents patient’s visit on physicians behalf (unlicensed)

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medical provider

physician or mid-level provider

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what scribe documents for outpatient visit

notes for past medical records
history & physical
lab + radiology results
physician interpretation of XRs and EKGs
assessment
plan

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scribes cannot

affect patient outcome
touch patients
handle bodily fluids or specimens
sign or authenticate
give verbal orders / submit EMR

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new patients

no previous records
longer visit
detailed chart

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established patients

previous records
shorter visit
concise chart

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types of clinic visits

diagnostic

2. health management / maintenance

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diagnostic visit

new problem
chief complaint / new symptom
goal to determine cause

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health management

check-up
chief complaint / management of chronic issue
goal to assess progress

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clinic flow:

check-in
physician eval
orders &amp; results
A &amp; P
check-out

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physician eval

A. H&P (history and physical):

HPI (history of present illness)
ROS (review of systems)
PE (physical exam)

B. All possible explanations (differential Dx)

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Orders & results

Orders: lab / imaging / procedures Results: during visit or in a few days

physician eval

A&P | Labs / imaging results

A&P

assessment: list of Dx plan: F/U, lifestyle or preventative, F/U for next appt

First person to speak to patient after in room

meaningful use requirements

1. vitals 2. smoking 3. weight 4. height 5. 1st degree family history (or "no pertinent F/Hx)

name of EMR system

allscripts

sections of chart

``` SOAP: S: HPI (story + context of chief complaint), ROS, Past history O: PE (provider's objective findings) A: diagnosis P: Tx + F/U ```

Where to document: patient complaint

HPI or ROS

Where to document: past Dx or surgery

Past history (includes family history)

Where to document: physician's observations

Where to document: study

Results

Where to document: current Dx

Assessment

Where to document: CBC

Results, A&P

Where to document: EKG

Results, A&P

Where to document: "pt came in for CP"

HPI, ROS

Where to document: "stubbed his toe last year"

ROS

Where to document: "no acute distress"

Where to document: HTN for many years

Past history, HPI

Where to document: tenderness in ABD

Where to document: pt mother has heart disease

famHx = Past history

Where to document: Dx is upper respiratory infection

A&P

Where to document: will be prescribed meds

A&P

Who enters allergies

MA, nurse (not scribe)

Meds to pay attn to

Past meds, any supplements that relate to current health issues.

"allergy" definition

anything that causes a rash, swelling, or difficulty breathing

high cholesterol

hyperlipidemia (HLD)

thyroid problem

hyperthyroidism / hyper

heart disease

CAD

heart attack

MI or CAD

heart failure

CHF

irregular heartbeat

A-fib

asthma

emphysema / chronic bronchitis

COPD

pneumonia

PNA

reflux

GERD (esophageal RD)

pancreatitis

diverticulitis

irritable bowel

IBS

bladder infection

UTI

dialysis

CRF

enlarged prostate

BPH (benign prostatic hypertrophy)

GPA

G: # pregnancies P: #deliveries / live births A: #losses

stroke

CVA

mini-stroke

TIA

brain bleed

CVA

depression

i drink a lot

ETOH abuse / alcoholism

blood clot in leg

LE DVT

low back pain

chronic low back pain

bulging disk

herniated disk or also DDD (degenerative disk)

arthritis

OA (osteoarthritis) or sometimes RA (joints)

join pain (chronic)

DJD (degenerative joint)

weak / fragile bones

osteoporosis / osteopenia

cancer

designate what kind ... carcinoma or cancer (CA) or leukemia, etc.

diabetes

DM (NIDDM / IDDM)

-ectomy

removal surgery

heart bypass surgery

CABG (with PMHx CAD)

stents (heart)

coronary stents

appendix

appendectomy

gallbladder removal

cholecystectomy

part of colon removed

partial colectomy

bag to collect stool

colostomy

stomach stapled

gastric bypass

part of lung removed

lobectomy

breast removal

mastectomy

hole in neck

tracheostomy

uterus removed

hysterectomy

ovary removed

ooporectormy

tubes tied

tubal ligation / vasectomy

prostate removed

prostatectomy (TURP)

neck artery cleaned

carotid endarterectomy

brain surgery

craniotomy

shunt (head)

ventriculoperitoneal

PICC

PICC (peripherally inserted central catheter)

joint repair

anthroplasty

neck fused

C-spine

back fused

L-spine

younger onset = what genetic risk?

higher risk.

parts of FHx

general (HTN, DM, CA), cardiac, pulmonary, GI, neuro, misc.

Age that cardiac disease indicated higher risk

55 or younger

social Hx

``` tobacco alcohol illicit drugs occupation living circumstances ```

age+ to report tobacco use (meaningful use)

13+

drug administration routes

inhaled oral injected

chronic alcoholism goes in which sections?

PMHx and SHx (chronic and abuse)

SHx - PEDS type of items

1. caretaker 2. daycare / school 3. brother / sisters 4. 2nd hand smoke 5. immunizations