Clinical History Flashcards
subjective information
your SUBject–info told by pt–goes in part A of note–historic info
Objective information
info you OBserve by examination (be sure to separate)
things pt complains of
symptom (i have a headache, my wrist hurts, my stomach hurts, pt’s chart reveals hypertension and hyperlipidemia, etc)
things you discove during physical exam
sign (right TM is cloudy, pupils are equal, round and reactive to light and accommodation, etc.)
subjective info
same area as symptom
old lab reported by pt or in chart
subjective
new lab ordered by us
objective
“well developed”
= typical healthy person for their age
memorize
PA comprehensive H & P Outline
if it’s not documented
it didn’t happen
if not documentaed
rational for lab or procedure should be easily inferred
CPT
current procedural terminology
time used
military time
ER
electronic records
documentation is key to the
billing and coding process
who would get comprehensive encounter
new pt, inpatient, yearly exam, vague CC, etc. (use common sense)
problem specific clinical encounter
specific problem–review of systems should relate back to CC
reliability
may need to verify with chart, family, interpreter–note in subjective reliability or who information is from
write chief complaint CC
“in patients own words”
CC
“why have you come to clinic today?”
HPI
history of present illness
OLDCARTESS
Onset Location Duration Characteristics Aggravating features Relieving features Timing/ Treatments tried Ever had before? associated Symptoms Summary--repeat everything back
CC
determines direction of the encounter
multiple CCs
may be separate dz processes OR connected to one underlying dz process
