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Lecture 3 Flashcards

1
Q

SOAP

A

subjective
objective
assessment
plan

organizes clinical info in patient’s chart.

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2
Q

subjective

A

patient’s feelings

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3
Q

objective

A

facts

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4
Q

history of present illness

A

HPI: patient’s chief complaint

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5
Q

review of systems

A

ROS: head-to-toe checklist of patient’s symptoms

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6
Q

intermittent

A

comes and goes

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7
Q

wax / wane

A

always present but changing in intensity (flares, chronic)

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8
Q

modifying factor

A

something that makes symptoms better / worse

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9
Q

subjective section includes:

A

chief complaint
HPI
ROS
(also past Hx?)

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10
Q

objective section includes:

A

vital signs
PE
orders
results

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11
Q

assessment section includes:

A

short description of progress from last visit

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12
Q

plan section includes:

A

F/U

treatment plan for each Dx

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13
Q

chief complaint

A

main reason for visit - subjective

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14
Q

HPI

A

story of chief complaint (illness story) - subjective

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15
Q

ROS

A

checklist of symptoms for all body systems - subjective

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16
Q

subjective info comes from whom:

A

patient
parent / pediatric
son/daughter
caregiver

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17
Q

chief complaint - which level of billing requires

A

EVERY LEVEL for reimbursement

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18
Q

Which is most commonly used non-reimbursable chief complaint

A

“F/U”

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19
Q

What must you use instead of:

check-up

A

(illness) “maintenance visit”

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20
Q

What must you use instead of:

F/U

A

(illness) management evaluation

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21
Q

What must you use instead of:

lab results

A

treatment options (for illness)

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22
Q

What must you use instead of:

medication refill

A

medication management (of illness)

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23
Q

why it is important to include chief complaint on every chart:

A

so it’s billable

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24
Q

HPI includes info like …

A
  1. story of symptoms and events that lead to clinic visit
  2. at beginning of chart written by MA
  3. reason for visit summary
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25
every subjective evaluation is followed by what kind of eval?
objective
26
how to check chart for completeness?
find the subjective complaints and follow them through the rest of your chart.
27
flow of HPI --> plan
``` HPI ROS PE Orders/results Assessment Plan ```
28
why is writing an accurate HPI important?
it's the basis for the workup that follows
29
HPI only contains what?
1. subjective info | 2. info related to chief complaint (directly)
30
things you document:
answer to every specific Q the doc asks
31
HPI content
``` element onset timing location quality severity modifying factors associated Sx context ```
32
element
description
33
onset
when chief complaint began
34
timing
constant/intermittent/wax-wane
35
location
where discomfort is
36
quality
quality of pain -- sharp, dull, aching, cramping
37
severity
how bad? mild, moderate, 0-10
38
modifying factors
what makes it better/worse
39
associated Sx
other symptoms accompany the complaint
40
context
anything else important (risk factors, anyone else sick)
41
evaluation for symptom experienced in past, important to document: (2)
1. anything new / different 2. how long ago symptoms occur 3. did they seek treatment at time 4. previous appt result/diagnoses
42
if pt had prior testing related to complaint, important to document: (4)
1. who ordered test 2. name of test (lab, CT, MRI) 3. results 4. Dx given
43
3 primary methods of structuring outpatient HPI
1. single complaint formula 2. multiple complaint formula (us) 3. chronologic (complex)
44
single complaint formula
best for patients with 1-2 complaints that have not been previously evaluated
45
single complaint formula includes:
``` age + sex complaint / onset quality, timing, location modifying associated Sx / pertinent negatives context ```
46
need to know where all the sections of the HPI go and be able to name them in a paragraph (single complaint)
HPI formula: 1. age / sex 2. chief complaint / onset 3. timing quality location 4. modifying factors 5. associated Sx 6. context
47
multiple complaint formula
multiple complaints, routine F/U for chronic illness, different treatment plans for different complaints (most often used for primary care)
48
multiple complaint formula includes
all the sections broken into paragraphs for each complaint para 1: cough para 2: HTN para 3: diabetes
49
multiple complaint where sections go:
intro para1: cough: onset, timing, modifying factors, etc. para2: HTS: progress since last visit, med compliance, etc. para3: headaches: onset, timing, modifying factors, etc.
50
chronologic:
complex story: multiple comorbidities, significant workup in past, established chronic patient for F/U precise order of events, evaluations, and symptoms (important to get chronology right for complex stories)
51
chronologic structure:
1. age/sex 2. PMH2 3. previous eval 4. previous Tx 5. current complaints 6. elements of 1st complaint 7. elements of 2nd complaint (etc.) 8. context general history ---> "today, ...."
52
HPI structure depends on multiple factors:
``` speciality clinic preference provider preference patient complexity # of patient complaints ```
53
first step in all formals is:
age/sex
54
HPI phrasing
complete sentences proper capitalization + punctuation spelling approved medical abbrev. (good! and write it out)
55
HPI phrasing Do/Don't
use days since Sx started don't use "got" ==> "worsened by palpitation ... " vary beginning of sentences describe specific Sx affecting pt "flu-like symptoms" document only things that are relevant to today's complaint.
56
R?OS:
phrased in simple list of positives and negatives + / - includes Sx in HPI no story / context placed here must never contradict HPI b/c they are subjective
57
constitutional
fever, weight loss, sweats
58
eyes
vision, eye pain, double vision
59
ENT
ear ache, nose bleed, sore throat
60
cardiovascular
chest paint, palpitations
61
respiratory
SOB, cough, wheeze
62
gastrointestinal
abd pain, NVD, black stools
63
genitourinary
dysuria, frequency
64
musculoskeletal
joint pain, muscle pain
65
integumentary / skn
rash, itching, abrasion, laceration
66
neurological
headache, syncope, numbness
67
psych
depression/anxiety
68
endocrine
polyuria, polydipsia
69
hemotologic/lymph
bleeding gums, easy bruising, swollen lymph nodes
70
immunologic
HIV / AIDs
71
physician lead ROS
physician reviews all body systems and scribe documents in realtime. 1. type quickly 2. docs type fast 3. EHRs have check boxes and template lists of Sx. -- avoid medical fraud

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