Medical Documentation II

Question 1

What is the acronym VITAMIN C?

Answer 1

A mnemonic to remember potential causes for differential diagnoses.

• Vascular
• Infection
• Trauma
• Anatomic
• Metabolic
• Iatrogenic/In the blood
• Collagen vascular

Question 2

What is the difference between subjective and objective information, with regard to a SOAP note?

Answer 2

Subjective: what the patient tells you

• CC
• HPI (OLDCARTS & pertinent +/-)
• Summarized PMH, PSH, SH, allergies, medications, and ROS that are RELEVANT to the CC

Objective: what you observe or see

• Vital signs, then general appearance
• Then the rest of the physical exam pertinent to the CC and pertinent +/- in the history
• Any pertinent lab/imaging or diagnostic data

Question 3

What are the elements of a focused history or NBME note?

Answer 3

History: Describe the history you just obtained from this patient. Include information (pertinent +/-) relevant to this patient’s problem(s) from the CC through the ROS.

Physical Examination: Describe any +/- findings relevant to this patient’s problem(s). Be careful to include ONLY those parts of examination you performed in this encounter. Always list vital signs first, then general appearance, then anything else pertinent in the exam related to your chief complaint.

Data Interpretation: Based on what you have learned from the HPI and PE, list 3 diagnoses in the differential diagnosis that might explain this patient’s complaint(s), from most to least likely, with supporing +/- findings from the HPI and PE. Lastly, list the diagnostic studies (if any) you would order for this patient (e.g., labs, imaging, ECG, procedures, consults, additional studies, etc.).