History Taking & Medical Documentation Flashcards
What are the goals of the patient assessment?
- Define the patient’s problems accurately
- Perform an analysis on a subjective & objective assessment (signs/symptoms)
What is the difference between subjective and objective assessments?
Subjective:
- Patient’s perspective
- How do they feel
- Symptoms they can describe
Objective:
- Examiner’s perspective
- What can you measure/observe
- These are signs, not symptoms
What are the 5 parts of the Problem Oriented Medical System (POMS)?
- Database (medical record)
- Problem list
- Initial plan (goals)
- Progress notes
- Discharge summary
What is the process for conducting an initial assessment?
- Receive referral
- Read patient’s file
- Discuss with medical and/or nursing staff
- Introduce yourself to patient
- Share understanding of the story so far
- Fill in the history gaps & physio-specific data
- Observe patient while taking history
- Perform physical assessment
What are the key bits of information in the patient’s file?
- Personal details (name, where the live)
- Assessment/progress notes
- Anaesthetic & operation reports
- Consultation notes (e.g. medical rounds, APS) - what is the medical plan?
- Other records (spirometry results, biochemistry, chest x-ray etc)
What is the APS?
Acute pain service, manage surgical patients’ pain levels
What do the following abbreviations mean? TKR HTN NKDA Aim D/C in 2/7
TKR: Total knee replacement
HTN: Hypertension
NKDA: No known drug allergies
Aim D/C in 2/7: Aiming for discharge in 2 days
What are the key components of the bedside chart?
- Observations
- Medications
- Nursing care plan
- Fluid balance chart
What are some key elements of taking a patient history?
- Professional & conservative
- Build rapport
- Explain your understanding of their story
- Ask questions to fill in the gaps
- Record patient’s own words
What is the structure of the subjective assessment?
- History of presenting illness (HPI)
- Past medical history (PMH)
- Social history (SHx)
What are some of the cardio-specific questions regarding symptoms (HPI)?
- Time course of current symptoms
- Mode of onset/pattern
- Site/radiation of pain
- Character
- Severity
- Aggravating/easing factors
- Associated symptoms
What are symptoms?
- Something that someone complains about
- Perceptible change in the body/function
- Only perceptible to the patient
What can be both a symptom and a sign?
Wheezes
What is dyspnoea?
- Breathlessness associated with distress
- Awareness of increased respiratory effort
- Unpleasant, inappropriate
What is the theory of dyspnoea?
It’s a result of a mismatch between central respiratory motor output and incoming afferent info from receptors in airways, lungs, chest wall structures
What is the relationship between dyspnoea and respiratory muscles?
Frequently occurs when there is an increased burden on the respiratory muscles or when they have become weak
What are the mechanisms of dyspnoea?
- Added load on mechanics of breathing (altered compliance - hyperinflation or altered airway resistance)
- Respiratory muscle weakness
- CV deconditioning
- Psychological factors
What do the following abbreviations mean?
SOB
SOBOE
PND
SOB: Shortness of breath
SOBOE: Shortness of breath on exertion
PND: Paroxysmal nocturnal dyspnoea (breathlessness only at night, usually after lying flat)
What are the primary and secondary reasons for decreased exercise tolerance?
Primary: Due to disease process (e.g. breathlessness/fatigue)
Secondary: Due to inability to exercise causing reduction in fitness
What are some of the questions concerning exercise tolerance?
- Normal PA levels versus now
- What type of activities cause problems?
- Distances achieved (on flat, on stairs)
- What subjectively limits exercise?
What is important to exclude when considering chest pain?
Pain of cardiac origin
What are some of the causes of chest pain?
- Pulmonary embolism (PE)
- Angina
- Trauma
- Surgery
- Pneumonia, pleural effusion, pneumothorax
- Musculoskeletal
What are some types of arrhythmias?
Arrhythmias (without rhythm)
- Atrial fibrillation (AF)
- Ventricular ectopic beats (VEB)
When is cough needed?
- When mucociliary clearance is non-effective or there is an increased amount of sputum (reflex, protective mechanism)
- When stimulated by allergens
What may persistent cough be indicative of?
- Respiratory disease
- Secondary to medications (e.g. ACE inhibitors)
- Post-nasal drip or reflux
What is an important question to ask a patient about cough?
Is the cough normal for you?
What is the normal amount of sputum for an adult?
Approx 100mL per day
What do you need to consider about sputum?
- Colour (usually white, clear & mucoid)
- Consistency
- Amount
- Daily pattern
- Ease of clearing
What is haemoptysis?
Blood in the sputum
When is excess sputum most common?
In suppurative lung diseases, e.g. cystic fibrosis, bronchiectasis
What is suppurative lung disease characterised by?
Chronic wet cough & progressive lung damage
What are wheezes caused by?
- Narrowing of major intrathoracic airway (asthma)
- Sputum or airway obstruction
What is stridor?
- Exaggerated wheezing
- Extrathoracic obstruction
- Mainly during inspiration
What are the important components of social history?
- Who do they live with
- Where do they live
- Support/services (e.g. meals on wheels)
- Previous mobility/function/daily activities
- Usual exercise tolerance
- Smoking
- Usual cough/sputum clearance
- Previous physio Rx
What are the essential hospital requirements for documentation?
- Patient ID sticker on pages
- Black pen
- Write directly under previous entry, within margins
- Date, time
- Legible, error correction
- Approved abbreviations
- Consent documented
- Risks/warnings
- Discharge summary
- Signed, print name, designation
- Co-signed by supervisor
What relevant communications should be documented?
- Conversations with medical staff
- Handovers from another physio
- Instructions to nursing staff
- Referrals
- Discharge/transfer summaries
What is the general agreement based on for medical notes?
Subjective
Objective
Assessment
Plan
What needs to be documented during the initial assessment (only needs to be done once)?
- HPI (Reason for admission, dates of procedures, progress/issues)
- PHx (Known conditions/diagnoses, previous surgeries/procedures)
- SHx (home situation, previous mobility, activities/sports, smoking/alcohol)
What needs to be documented following every interaction with patients?
- Subjective assessment
- Objective assessment
- Problem list
- Treatment (Rx)
- Reassessment (ReAx)
- Goals (SMART)
- Plan
What needs to be documented in the objective assessment?
- Obs stable/febrile
- Resp (SpO2, FiO2, ABG, RR, auscultation, palpation, cough, observations)
- Cardio (HR, rhythm, BP)
- Functional (mobility, balance, STS, gait)
- Attachments (IV, drains, IDC, monitors)
What should be included in the physio plan?
- Instructions for nursing staff
- Patient’s independent physio program
- When you plan to see them again
- Goals/plan for subsequent treatment
