Charting Components Flashcards
what does the emergency department treat
emergent, urgent, and non-urgent conditions
what does urgent care treat
urgent and non-urgent conditions
what do outpatient clinics treat
family medicine/internal medicine or specialty medicine
what is the chief complaint (CC)
the reason the patient is coming in to be seen by the provider
what are the types of chief complaints in the emergency department
an acute complaint
what are the types of chief complaints in the outpatient clinic
an acute complaint, new patient, follow up visit
what does HPI stand for
history of present illness
what is the HPI for
to expand and further describe the chief complaint. subjective information
what does ROS stand for
review of symptoms
what is the ROS for
this section of the note is a list of body systems with common symptoms for each body system. subjective information
what does a typical review of systems include
constitutional, eyes, ENT, heme/lymph, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, integumentary, allergy/immunology, endocrine, psychiatric
what is the past medical, social, and family history section for
where we find the patients medical history, surgical history, family history and social history
what does the past medical history include
long term, diagnosed, medical conditions the patient has
what does the past family history include
long term diagnosed medical conditions for a patients immediate family members
what does the past social history include
social habits affecting the patients medical history , commonly asked about tobacco and alcohol and drug use
what does the physical exam explain
it is a list of body systems where we document what the medical provider finds when examining the patient. objective findings
what is the impression assessment diagnosis
the section of the note where we record the diagnoses which is a cause of the patients symptoms
what would a normal physical exam for the general section look like
alert. no acute distress. non-toxic appearing
what would a normal physical exam for the head/neck section look like
normocephalic, atraumatic, neck supple
what would a normal physical exam for the eyes section look like
pupils are equal, round, and reactive too light. extra ocular movements intact
what would a normal physical exam for the ENT section look like
external ears are normal
what would a normal physical exam for the respiratory section look like
normal respiratory effort. clear to auscultation, no wheezing, rales, or rhonchi
what would a normal physical exam for the cardiovascular section look like
normal rate, regular rhythm, no murmurs, rubs or gallops
what would a normal physical exam for the gastrointestinal section look like
soft, no tenderness to palpitation, no guarding or rebound. no organomegaly. normal bowel sounds
what would a normal physical exam for the musculoskeletal section look like
no obvious deformities. no significant edema
what would a normal physical exam for the skin section look like
no obvious rashes
what would a normal physical exam for the neurological section look like
alert and oriented x3. normal strength. no focal neurological deficit
what would a normal physical exam for the psychiatric section look like
normal affect
