Overview of Medical Notes Flashcards
1
Q
Why do we take notes?
A
- Increase quality of patient care
- Less redundancy
- Physician reimbursement
- Legal testimony
- Communication between providers
- Scientific knowledge and research
2
Q
What to document?
A
Only things you have personally witnessed or verify through credible source, cite outside sources
3
Q
What are the parts of a medical note?
A
SOAP
- Subjective
- Objective
- Assessment
- Plan
4
Q
Chief Complaint
A
Subjective
- State in the patients own words
- Symptoms and goals ARE chief complaints, DON’T use diagnosis
- Only use medical terms if patient uses them
5
Q
History of Present Illness (HPI)
A
Subjective
- Who, Age, Gender, History, Where, What
- Pertinent past medical history: Known diagnosis and Obstetric History
- Record in Chronological Order
- Use Abbreviations sparingly
- Patients own words
- Problem pertinent ROS may be included
- Document limitations: Dementia, Alcohol intoxication, Language barrier
6
Q
Family History
A
Subjective
- Includes problems in immediate family and direct lineage (Specify maternal/paternal)
- Living? How and when did they die?
- Depending on disease inheritance we may need more complete history (Aunts, Uncles, cousins)
7
Q
Social History
A
Subjective
- Alcohol, tabacco, drugs (start and quit)
- Employment, exposures, exercise
- Habits, diet, relationships
- Religion (as it relates to treatment)
- Children history more difficult: Passive exposure, daycare, sports, activity level
8
Q
Past Medical/Surgical History (including obstetric)
A
Subjective
- Known medical diagnosis
- Surgeries (date and indication)
- Previous hospitalizations
- Childhood illness and immunizations
- Include alternative medicine treatments
- Obstetric History (pregs/outcome)
9
Q
Medications/Allergies
A
Subjective
- Current and recent medications
- Include other herbal supplements
- Allergies can be to food, drugs or environmental exposures (list type of reaction if known)
10
Q
Review of symptoms
A
Subjective
- Record positive/negative for each symptom
- Only recent symptoms (chronic problems => HPI)
- “All other systems negative” Circumstantial
11
Q
Physical Examination
A
Objective
- Include general impression of patient
- VITAL SIGNS
- Serial examinations may go in department course
12
Q
Special Tests & Procedures
A
Objective
- Name of procedure and indication
- Informed consent
- Individual performing procedure
- Location on body
- Specific equipment used
- General Technique
- Complications
- Outcome of procedure
13
Q
Lab Results
A
Objective
- May be in MDM
- LIst name of investigation followed by: Pertinent negatives, Positive findings, “Otherwise WNL” (within in normal limits)
14
Q
Radiologic Studies
A
Objective
- Give full name of study with modifiers
- Include radiologist’s name
- Use the “Impression” given on the report
- Include details when relevant
15
Q
Department course
A
Objective/Assessment
- May be combined with MDM
- Include tine when actions were taken and patient response
- List preventative measures
- Especially important in trauma/critical care
