L2: Foundations of Health Assessment 2 Flashcards
What needs to be included in the SOCHx section of the medical record?
- Personal status (occupation, relationship) - Habits (etoh, smoking incl amt and frequency), illicit drugs, diet, caffeine, sexual history, travel (exposures), military service, exercise, self care, home conditions, access to care, religious / cultural preferences
What needs to be included in the medication section of the medical record?
- List all medications the patient is taking (prescription and non-prescription including OTC, herbal remedies, supplements and vitamins) - Include: name, dose (per pill, total), number of pills, route, frequency, last dose/intake
Describe the components of the SOAP note.
- S: Subjective: has CC, HPI (incl PROS), meds, allergies, PMHx, PSHx, FMHx, SOCHx, ROS - O: Objective: vital signs, general statement, physical exam, studies - A: Assessment: differential diagnoses, chief complaint, preexisting conditions, risk factors, health maintenance, diagnostic findings, osteopathic findings, differential for each medical problem - P: Plan: intention/plan for each problem: tests, osteopathic treatment, other treatments, referrals, return plan, education
Other Mnemonic’s for HPI:
- CODIERS - C: chronology - O: onset - D: description - I: intensity - E: exacerbating factors - R: remitting factors - S: associated symptoms - OLDCARTS - O: onset - L: location - D: duration - C: character - A: aggravating / alleviating - R: radiation - T: timing - S: severity
What are the two types of physical examination?
- Basic: basic function of system, if normal, don’t proceed to expanded - Expanded: used if chief complaint involves that system, has co-morbidity in that system, fails a basic test
Explain characteristics of the physical exam that should be included in the objective section of the medical record.
- Follow step by step approach - HEENT, CARDIAC, LUNGS, ABDOMEN, GENITAL, BREAST, SKIN, EXTREMITIES, NEUROLOGICAL - Relate pex findings to process of inspection, palpation, auscultation and percussion - Location of findings important - Incremental grading (mild, moderate, severe) - Masses, lesions, organs - Discharge
What is the basic outline of the medical record?
- Identification - Informant - Chief complaint (s) - HPI incl PROS - Medications - Allergies - PMHx, PSHx - FMHx - SOCHx - ROS - Phys Ex - Studies - Assessment - Plan
What is the ROS?
- ROS: review of systems - Obtain information about all body systems
What needs to be included in the FMHx section of the medical record?
- Blood relatives, parents, siblings, children’s, grandparents - age, alive/deceased, cause of death, health issues
What needs to be included in the PSHx section of the medical record?
- Type of surgery - Reason for surgery (except for wisdom teeth or c-section) - Date of surgery - Hospital where surgery occurred - Complications - Procedures can be included in this section
What is the procedure if an error is made in a paper medical chart?
Draw a single line through the error and write the date with your initials.
Characteristics of chief complaint (CC):
- reason for seeking care or presenting problem - placed in quotes - brief - several concerns (list according to severity, highest first)
What needs to be included in allergies section of the medical record?
- Drugs, environmental, food allergies - Reaction that occurs - Establish if side effect or true allergy
What are general guidelines to keep in mind for paper chart?
- Must be legible - Dated and timed on each page - No erase (single line with date and initials) - No line blank - Sign each page at bottom
What is the difference between a sign and a symptom?
- Sign: observation or palpable phenomenon associated with given disorder (incl vitals) – objective - Symptom: manifestation of disease of which pt is usually aware – subjective
