History-Taking for Wellness Exams, Episodic Visits, and Chronic Care Management Flashcards
What does the scope and degree of detail in history-taking depend on?
the chief concern
complexity of the medical condition
clinician’s goals for the visit
What is the purpose of a wellness exam?
preventing illness, disease, and health problems
detecting problems at an early stage
General components of a wellness exam
- comprehensive, culturally sensitive history and physical
- anticipatory guidance
- addressing risk factors
- motivational interviewing to reduce identified risk factors
- ordering appropriate immunizations and laboratory/diagnostic procedures
How does a wellness exam differ from a episodic visit or chronic care management visit?
wellness exams are focused on risk factors NOT a presenting problem
What should PMH include for a wellness exam?
- past medical conditions, hospitalizations, surgeries, injuries
- medications or supplements be observant of opiate use
- allergies
PMH for women should include
- menstrual history
- gynecological history
- sexual history
- obstetric history
Who should be included in a family history?
patient’s grandparents, parents, siblings, and children
What should be asked during a menstrual history exam?
age of menarche, length and frequency of cycle, type and amount of flow, associated symptoms, FDLMP, menopause, any hormone replacement therapy
What should be asked during a gynecological history exam?
last pap smear and results, abnormal vaginal discharge, dryness, lesions
What should be asked during a sexual history exam?
- sexual history: number of partners, preference, abuse history, safety, STI, contraception method
What should be asked during a obstetric history exam?
GPA or TPAL, complications during pregnancy or labor, vaginal, induced, or c-section, fertility
What should be reviewed during a family history of a wellness exam??
health status of family members, pattern of disease(s), cause of death
What is included in a social history of a wellness exam?
age and gender appropriate review of: marital status living arrangement home conditions social support occupational history drug use alcohol intake smoking/tobacco history religious/spiritual ideals cultural preference sexual history
What is the purpose of a ROS?
to gather essential information on current or potential disease processes that may otherwise go unnoticed
What is important to consider when obtaining a history on a patient with a disability?
The patient is the expert.
What are special considerations for older adults during a wellness exam?
medication appropriateness functional assessment (ADLs, fall risk, home safety) cognitive function advanced directives/POAs risk for depression
What is an example of a screening tool for medication appropriatenss?
AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
What are some examples of a model used to assess fall risk for older adults?
Hendrick II Fall Model
Fall Prevention Checklist for Older Adults
What is an example of a cognitive assessment tool for older adults?
Mini-Cog
PHQ-9 or PHQ-2
A depression screening tool (patient health questionnaire-9 or 2)
Where can you find recommendations on preventative care services?
www. uspreventiveservicestaskforce.org/Page/Name/grade-definitions
https: //epss.ahrq.gov/PDA/index.jsp
What letter grade warrants the highest certainty for net benefit in regards to preventive services?
Grade A
What type of visit accounts for the majority of visits to a clinician?
episodic visit
What is the general framework for history taking during an episodic visit?
Chief concern (CC) History of present illness (HPI) Past medical history (PMH) Family history (FH) Social history (SH) Review of systems (ROS)
How should the HPI begin?
with the chief concern (CC)
What is the most helpful component of developing a differential diagnosis list?
the HPI
What are the 8 key elements of the HPI?
- location
- quality
- severity
- duration
- timing
- context
- modifying factors
- associated signs and symptoms
What is OLD CARTS?
A mnemonic to help remember the 8 key elements of HPI.
Onset, Location, Duration, Character, Aggravating factors/associated symptoms, Relieving factors, Timing, Severity
How is the ROS performed during an episodic visit?
- problem-pertinent ROS
- extended ROS
- complete ROS
What type of physical exam should be performed during an episodic visit?
problem-focused
expanded problem-focused
detailed
comprehensive
What body areas should be included in a physical examination?
head/face neck chest abdomen genitalia, groin, buttocks back/spine extremities
What reference should be utilized when considering laboratory and diagnostic testing?
choosingwisely.org
What are among the leading causes of death and disability?
chronic conditions
What are some examples of chronic conditions?
heart disease cancer chronic lung disease stroke alzheimer's disease diabetes chronic kidney disease
What should chronic care management include?
BOTH face-to-face and non-face-to-face visits
What should be the focus of chronic care management?
patient’s relationship with the healthcare TEAM
establishing AND achieving health goals
coordination of community and social services
medical, functional, and psychosocial assessment
preventive care
What should the treatment plan include for chronic care management?
lifestyle modifications
pharmacological interventions
self-management support
education
What is a chronic care management visit MOST focused on?
lifestyle modifications and counseling
What are potential benefits of team-based care?
clinician delegation
improvement in quality of care
reduction in healthcare cost
more patient-centered
How would a clinician document HPI during a chronic care visit?
By utilizing 6 elements: SDT CMA
- Severity
- Duration
- Timing
- Context
- Modifying factors
- Associated S/S
How is a PMH, FH, and SH obtained during a chronic care visit?
same as wellness and episodic visits
