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SCRIBE > Lecture 3 > Flashcards

Lecture 3 Flashcards

1
Q

SOAP

A

subjective
objective
assessment
plan

organizes clinical info in patient’s chart.

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2
Q

subjective

A

patient’s feelings

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3
Q

objective

A

facts

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4
Q

history of present illness

A

HPI: patient’s chief complaint

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5
Q

review of systems

A

ROS: head-to-toe checklist of patient’s symptoms

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6
Q

intermittent

A

comes and goes

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7
Q

wax / wane

A

always present but changing in intensity (flares, chronic)

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8
Q

modifying factor

A

something that makes symptoms better / worse

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9
Q

subjective section includes:

A

chief complaint
HPI
ROS
(also past Hx?)

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10
Q

objective section includes:

A

vital signs
PE
orders
results

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11
Q

assessment section includes:

A

short description of progress from last visit

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12
Q

plan section includes:

A

F/U

treatment plan for each Dx

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13
Q

chief complaint

A

main reason for visit - subjective

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14
Q

HPI

A

story of chief complaint (illness story) - subjective

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15
Q

ROS

A

checklist of symptoms for all body systems - subjective

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16
Q

subjective info comes from whom:

A

patient
parent / pediatric
son/daughter
caregiver

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17
Q

chief complaint - which level of billing requires

A

EVERY LEVEL for reimbursement

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18
Q

Which is most commonly used non-reimbursable chief complaint

A

“F/U”

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19
Q

What must you use instead of:

check-up

A

(illness) “maintenance visit”

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20
Q

What must you use instead of:

F/U

A

(illness) management evaluation

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21
Q

What must you use instead of:

lab results

A

treatment options (for illness)

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22
Q

What must you use instead of:

medication refill

A

medication management (of illness)

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23
Q

why it is important to include chief complaint on every chart:

A

so it’s billable

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24
Q

HPI includes info like …

A
  1. story of symptoms and events that lead to clinic visit
  2. at beginning of chart written by MA
  3. reason for visit summary
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25
Q

every subjective evaluation is followed by what kind of eval?

A

objective

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26
Q

how to check chart for completeness?

A

find the subjective complaints and follow them through the rest of your chart.

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27
Q

flow of HPI –> plan

A 
HPI
ROS
PE
Orders/results
Assessment
Plan
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28
Q

why is writing an accurate HPI important?

A

it’s the basis for the workup that follows

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29
Q

HPI only contains what?

A
  1. subjective info

2. info related to chief complaint (directly)

30
Q

things you document:

A

answer to every specific Q the doc asks

31
Q

HPI content

A 
element
onset
timing
location
quality
severity
modifying factors
associated Sx
context
32
Q

element

A

description

33
Q

onset

A

when chief complaint began

34
Q

timing

A

constant/intermittent/wax-wane

35
Q

location

A

where discomfort is

36
Q

quality

A

quality of pain – sharp, dull, aching, cramping

37
Q

severity

A

how bad? mild, moderate, 0-10

38
Q

modifying factors

A

what makes it better/worse

39
Q

associated Sx

A

other symptoms accompany the complaint

40
Q

context

A

anything else important (risk factors, anyone else sick)

41
Q

evaluation for symptom experienced in past, important to document: (2)

A
  1. anything new / different
  2. how long ago symptoms occur
  3. did they seek treatment at time
  4. previous appt result/diagnoses
42
Q

if pt had prior testing related to complaint, important to document: (4)

A
  1. who ordered test
  2. name of test (lab, CT, MRI)
  3. results
  4. Dx given
43
Q

3 primary methods of structuring outpatient HPI

A
  1. single complaint formula
  2. multiple complaint formula (us)
  3. chronologic (complex)
44
Q

single complaint formula

A

best for patients with 1-2 complaints that have not been previously evaluated

45
Q

single complaint formula includes:

A 
age + sex
complaint / onset
quality, timing, location
modifying
associated Sx / pertinent negatives 
context
46
Q

need to know where all the sections of the HPI go and be able to name them in a paragraph (single complaint)

A

HPI formula:

  1. age / sex
  2. chief complaint / onset
  3. timing quality location
  4. modifying factors
  5. associated Sx
  6. context
47
Q

multiple complaint formula

A

multiple complaints, routine F/U for chronic illness, different treatment plans for different complaints
(most often used for primary care)

48
Q

multiple complaint formula includes

A

all the sections broken into paragraphs for each complaint

para 1: cough
para 2: HTN
para 3: diabetes

49
Q

multiple complaint where sections go:

A

intro

para1: cough: onset, timing, modifying factors, etc.
para2: HTS: progress since last visit, med compliance, etc.
para3: headaches: onset, timing, modifying factors, etc.

50
Q

chronologic:

A

complex story:
multiple comorbidities, significant workup in past, established chronic patient for F/U

precise order of events, evaluations, and symptoms

(important to get chronology right for complex stories)

51
Q

chronologic structure:

A
  1. age/sex
  2. PMH2
  3. previous eval
  4. previous Tx
  5. current complaints
  6. elements of 1st complaint
  7. elements of 2nd complaint (etc.)
  8. context

general history —> “today, ….”

52
Q

HPI structure depends on multiple factors:

A 
speciality
clinic preference
provider preference
patient complexity
# of patient complaints
53
Q

first step in all formals is:

A

age/sex

54
Q

HPI phrasing

A

complete sentences
proper capitalization + punctuation
spelling
approved medical abbrev. (good! and write it out)

55
Q

HPI phrasing Do/Don’t

A

use days since Sx started
don’t use “got” ==> “worsened by palpitation … “
vary beginning of sentences
describe specific Sx affecting pt “flu-like symptoms”
document only things that are relevant to today’s complaint.

56
Q

R?OS:

A

phrased in simple list of positives and negatives + / -
includes Sx in HPI
no story / context placed here
must never contradict HPI b/c they are subjective

57
Q

constitutional

A

fever, weight loss, sweats

58
Q

eyes

A

vision, eye pain, double vision

59
Q

ENT

A

ear ache, nose bleed, sore throat

60
Q

cardiovascular

A

chest paint, palpitations

61
Q

respiratory

A

SOB, cough, wheeze

62
Q

gastrointestinal

A

abd pain, NVD, black stools

63
Q

genitourinary

A

dysuria, frequency

64
Q

musculoskeletal

A

joint pain, muscle pain

65
Q

integumentary / skn

A

rash, itching, abrasion, laceration

66
Q

neurological

A

headache, syncope, numbness

67
Q

psych

A

depression/anxiety

68
Q

endocrine

A

polyuria, polydipsia

69
Q

hemotologic/lymph

A

bleeding gums, easy bruising, swollen lymph nodes

70
Q

immunologic

A

HIV / AIDs

71
Q

physician lead ROS

A

physician reviews all body systems and scribe documents in realtime.

  1. type quickly
  2. docs type fast
  3. EHRs have check boxes and template lists of Sx. – avoid medical fraud

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