Assessment Flashcards
1
Q
what is the assessment formula?
A
Diagnoses + Summary of visit= assessment
2
Q
the assessment always includes?
A
the diagnoses
3
Q
what can the assessment also include?
A
a brief summary of the HPI (chief complaint and onset only)
a brief summary of the PE (pertinent findings only)
Summary of lab/imaging results (if new since last visit)
prognosis (or justification for further testing or medication)
4
Q
what are three types of assessment structures?
A
simple statement
brief summary
comprehensive summary
5
Q
what is included in a simple statement
A
age and sex of patient
past medical history only if revelant
Dx
6
Q
what is included in the brief summary
A
age and sex of patient past medical history if relevant physical exam findings if relevant results if new and revelant Dx DDx if no definitive diagnosis is found
7
Q
what is included in the comprehensive summary?
A
basically everything
