Intro To Clincial Inquiry Flashcards
What is the purpose of documentation?
- Memory aid
- Communication
- Quality assessment and research
- Administrative and legal matters
How to document when there is no EMR?
- Use permanent ink
- All entries should be noted by date and time
- Include your signature
- Never alter an entry
- No blank lines between entries
What should you do if you have omitted data?
If something is omitted do NOT add the information
*make a separate entry (addendum)
*on the addendum include the date, time, initials
How to correct a mistake when there is no EMR?
- Draw a single line through the error
- Label as an error
- The error, correction, and addendum should be initialed with time and date of the correction
When to conduct a “Complete History and Physical”
When a person presents as a new patient to a practice setting
What are the multiple reasons to conduct a “Complete History and Physical”
- Pre-op physical
- Annual physical
- Wellness exam
- Medicare Annual
- Pre-participation sports physical
- Pediatric Well Child Check (WCC)
What is a Pre-op appointment? (Comprehensive H&P)
Patient needs clearance from clinician for surgery
-Ensure surgical team is aware of al health conditions and okay for surgery
What happens during an Annual exam? (Comprehensive H&P)
The patient is overall healthy and comes in once a year for a visit
What happens during a wellness exam? (Comprehensive H&P)
The focus is the patients wellness, ensures all Health Promotion & Disease Prevention items are being address and up to date
*No problems or conditions are discussed or evaluated
What happens during a Medicare wellness appointment? (Comprehensive H&P)
The focus is wellness but if the patient has concerns they ARE able to address and bill
What happens during a Pre-Participation sports physical? (Comprehensive H&P)
Identify and risk factors that would impact students athletes ability to safely play sports
What happens during a Well Child Check? (Comprehensive H&P)
- Developmental milestones
- Immunizations
- Birth history
- Concerns of parents
5.Anticipatory guidance
What are the components of the Complete H&P?
- Comprehensive health history
- Complete physical exam
- Database of labs, radiologic and other studies
- Assessment
- Plan
Where does the database of labs go in a complete H&P?
ALWAYS in objective
*AFTER the physical examination documentation
What are the components of a complete history?
- Patient identifying information
- Source and reliability
- CC
- History of present illness
- Past Medical History
- Past Surgical History
- Medications
- Allergies
- Family History
- Social History
- ROS
What is the patient identifying information?
- Patient name (HIPAA)
- DOB
- Medical record number (HIPAA)
What are some things for source and reliability of information?
- Patient, caregiver, chart, spouse
- Reliable?
Where does the lab and diagnostic studies go?
After the physical exam
*only results that you have at the time
Assessment is also consider what?
Diagnosis
When is a SOAP Note used?
- Used for an established patient
- Used to document a problem oriented complaint
What is the “S” of SOAP
Subjective
1. What the patient tells you, in their own words
*historical information
What is the “O” in SOAP note?
Objective
1. Physical exam findings and results of diagnostic tests
*Use medical terminology
What is the “A” in SOAP?
Assessment
1. Your diagnosis
*May include differential diagnoses
What is the “P” in SOAP?
Plan
1. Course of action
What are the components in the Subjective Data?
- CC
- History of present illness
- Pertinent medications and allergies
- Pertinent family history
- Pertinent social history
- Pertinent ROS
- Pertinent PMH PSH
What does OLDCARTS stand for?
O: onset
L: Location
D: duration
C: character
A: Alleviating/ Aggravating
R: radiation
T: Temporal Pattern or Timing
S: Symptoms or severity
What does OPQRST stand for?
O: Onset
P: Palliative or provocative
Q: Quality of pain
R: Region affected or radiation
S: Severity of pain
T: Timing
What are pertinent positives? (Subjective)
- Data that helps support or suggest one diagnosis more than another
- Presence of symptoms
What are Pertinent negatives?
- Absence of symptoms
- Eliminates diagnosis
- Helps rule out other diagnosis
What to include in the “Objective” part of the SOAP Note
- What you see or observe first hand
- Heading Format
- Include pertinent positive and negatives
What is the Objective format of a SOAP note?
- Vital signs and general assessment
- Focused physical exam
- Procedure notes
- Pertinent laboratory or diagnostic results
What is the Assessment of a SOAP note?
- The diagnosis
*Subjective+Objective=assessment - Can use a presumptive diagnosis
*symptom, complaint, condition, or problem
What does ICD-10-CM coding stand for?
International Classification of Diseases 10th edition clinical modification
What is the purpose of ICD-10-CM coding?
Used to determine the level of reimbursement for medical services
What is the Plan part of SOAP note?
- Plan of care
*Tests
*Pharmaceutical
*HPDP
*Patient education
*Follow-ups
How should the plan be written out to match the assessment portion?
- Assessment
- Assessment
- Plan
- Plan
*Correlate the diagnosis with the same number in the plan
What does VINDICATES-P stand for? (Differential diagnosis)
V: Vascular and hematologic
I: Inflammatory or infections
N: Neoplastic or nutritional
D: degenerative or deficiency
I: Idiopathic, iatrogenic
C: Congenital
A: Autoimmune
T: Traumatic
E: Endocrine
S: Specific organs
P: Psychosomatic
