OP 5: Assessment & Plan Flashcards
1
Q
Assessment
A
Diagnoses + Summary of visit
2
Q
Assessment must include:
A
- Age & sex of patient
- Dx or DDx
3
Q
Assessment may include:
A
- HPI elements
- Summary of PE
- Summary of lab/imaging results
- Prognosis
4
Q
Assessment Basic Structure
A
- Age and Sex
- PMHx
- Diagnoses
5
Q
Assessment Objective Summary
A
- Age and Sex
- Diagnoses
- Relevant PE
- Results
6
Q
Comprehensive Assessment
A
- Age and Sex
- Diagnoses
- Relevant PE
- Results
- HPI elements
7
Q
Results
A
Must be:
1. New
2. Relevant
- Include:
- (+) results confirming diagnosis
- (-) results ruling out diagnosis
Summarize:
1. Name of test
2. Result of test
3. Why it was ordered
8
Q
Plan
A
A list outlining how the doctor will treat and/or monitor the patient
Includes:
- Recommended treatments for diagnosis
- Prescriptions ordered (Name, Dosage, Frequency)
- Studies/tests/labs/imaging
- Follow-up with other healthcare prof
- Follow-up for next appt.
9
Q
Billing
A
ICD = Diagnosis
- ICD: International Classification of Disease
