Clinical History

Question 1

subjective information

Answer 1

your SUBject–info told by pt–goes in part A of note–historic info

Question 2

Objective information

Answer 2

info you OBserve by examination (be sure to separate)

Question 3

things pt complains of

Answer 3

symptom (i have a headache, my wrist hurts, my stomach hurts, pt’s chart reveals hypertension and hyperlipidemia, etc)

Question 4

things you discove during physical exam

Answer 4

sign (right TM is cloudy, pupils are equal, round and reactive to light and accommodation, etc.)

Question 5

subjective info

Answer 5

same area as symptom

Question 6

old lab reported by pt or in chart

Answer 6

subjective

Question 7

new lab ordered by us

Answer 7

objective

Question 8

“well developed”

Answer 8

= typical healthy person for their age

Question 9

memorize

Answer 9

PA comprehensive H & P Outline

Question 10

if it’s not documented

Answer 10

it didn’t happen

Question 11

if not documentaed

Answer 11

rational for lab or procedure should be easily inferred

Question 12

CPT

Answer 12

current procedural terminology

Question 13

time used

Answer 13

military time

Question 14

ER

Answer 14

electronic records

Question 15

documentation is key to the

Answer 15

billing and coding process

Question 16

who would get comprehensive encounter

Answer 16

new pt, inpatient, yearly exam, vague CC, etc. (use common sense)

Question 17

problem specific clinical encounter

Answer 17

specific problem–review of systems should relate back to CC

Question 18

reliability

Answer 18

may need to verify with chart, family, interpreter–note in subjective reliability or who information is from

Question 19

write chief complaint CC

Answer 19

“in patients own words”

Question 20

CC

Answer 20

“why have you come to clinic today?”

Question 21

HPI

Answer 21

history of present illness

Question 22

OLDCARTESS

Answer 22

Onset
Location
Duration
Characteristics
Aggravating features
Relieving features
Timing/ Treatments tried
Ever had before?
associated Symptoms
Summary--repeat everything back

Question 23

CC

Answer 23

determines direction of the encounter

Question 24

multiple CCs

Answer 24

may be separate dz processes OR connected to one underlying dz process

Question 25

HPI

Answer 25

inseparable from CC–

Question 26

opening sentence of HPI

Answer 26

“patient is a __ yo male/female who presents with CC: “XXXXXXXX”

Question 27

Narrative

Answer 27

pt’s story in full sentences–NOT bullets

Question 28

Location

Answer 28

point with ONE finger at location

Question 29

Character

Answer 29

sharp, dull, deep, shallow, etc.

Question 30

Relievers

Answer 30

home therapy

Question 31

Ever had before

Answer 31

when, how, what did you do then, what was your dx?

Question 32

Symptoms associated

Answer 32

any and all–connect in mind and allow to lead to more questions

Question 33

Summary

Answer 33

feed back to pt what you heard

Question 34

After OLDCARTESS

Answer 34

ask more questions to R/I and R/O DDx

Question 35

Hemoptysis

Answer 35

Goodpasture syndrome

Question 36

CC

Answer 36

can you tell me why you came in? (opener)

Is there anything else you’d like to talk to me abt today? (closer)

Question 37

always double check

Answer 37

allergies and FH of disease (ask specific diseases)

Question 38

first menstruation

Answer 38

menarche

Question 39

distinct lymph node

Answer 39

gummy bear shaped like a jelly bean