DAY1 Flashcards
Define chief complaint
the main reason for the patient’s outpatient visit
Define EMR/EHR
Electronic medical record/ electronic health record
Define subjective
feeling
Define Objective
factual finding from the provider
Define Pain
Patient’s feeling of discomfort
Define Tenderness
Doctor’s finding of reproducible pain
Define acute
new onset, likely concerning
Define chronic
long-standing, not of direct concern
What are the 2 types of patients
new and established
Define new patient
1) a patient that has never been seen at the clinic or was seen greater than 3 years ago
2) no previous records
3) longer visit
4) detailed chart
Define established patient
1) a patient that has been seen at the clinic ( by any provider) within the last 3 years
2) previous records available
3) shorter visit
4) concise chart
What are the 2 types of visits
diagnostic and health management
Define diagnostic visits
1) new problems
2) chief complaint: new symptoms
3) goal is to determine the cause of the problem and appropriate treatment
Define health management visit
1) check up
2) chief complaint: routine physical or management of chronic problems
3) goal is preventative care and or assessing progress of ongoing medical problems
What is the flow of the clinic
1) Check in and Chief complaint
2) History and Physical
3) Orders and Results
4) Assessment and plan
5) Check out
What is part of the Physician: History and Physical ( H & P)
History of Present Illness ( HPI)
Review of Systems ( ROS)
Past History
Physical Exam (PE)
DDx ( only for diagnostic visits)
What are the component of the Medical Chart
S: history of present illness (HPI) and Review of Systems ( ROS)
O: Physical Examination (PE) and Orders and Results
A: Assessment
P: Plan
Where would you find the chief complaint in the chart
HPI OR ROS ( Subjective complaint)
Where would you find past diagnoses and surgeries
past history
Where would you find physician’s observations
physical exam ( objective evaluation)
Where would you find labs, imaging,studies
results
where would you find current diagnoses
assessment
where would you find treatment plan
plan
Medical term for high blood pressure?
Hypertension (HTN)
