Special Populations Presentation and Documentation DONT STUDY

Question 1

approach with specific populations

Answer 1

-obtaining preferred method of address
-nicknames
-first names, formal address
-“dear”, “sweetie”
-gender identity vs. gender pronouns
-which gender pronouns do you use
-new borns (birth to 30 days) and infants (1 month to 1 year)
-young and school aged children
-adolescents
-older adults
-lesbian, gay, bisexual, transgender adults
-pts with physical and/or sensory disabilities - dead, blin, wheelchairs

Question 2

challenging patient situations and behaviors

Answer 2

-silent
-talkative
-confusing narrative
-altered state or cognition
-emotional lability
-angry or aggressive
-flirtatious
-discriminatory - cont. care for pt, get assistance remove yourself from situation, cultivate therapeutic alliance, supervising clinicians responsibility
-states your discomfort
-limited intelligence
-burdened by personal problems
-nonadherent vs non-compliance
-with low literacy vs low health literacy
-limited language proficiency
-terminal illness or dying

Question 3

gathering information

Answer 3

-note about taking notes
-responding to emotional cues- name, understand/legitimize, respect, support, explore
-exploring pts perspective
-ICE- ideas, concerns and expectations, LC & I life context, impact
-FIFE- feelings, ideas, effect on function, and expectations
-extend of information
-type of history- comprehensive/problem oriented, ongoing/chronic problems, health maintenance, specialist

Question 4

purpose of clinical record

Answer 4

-reflects your analysis of pts health status and tracking their progress
-it documents the unique features of pts hx, exam, lab, and test results, assessment, and plan in formal written format
-patient record facilitates:
-clinical reasoning
-promotes communication and coordination among professionals who care for your pt
-documents pts problem and management for medicolegal purposes

Question 5

clinical record

Answer 5

-legal document
-most documentation is done on EHR but there is value in writing it out by hand
-only use black ink
-only particular abbreviations are allowed -> may differ from institution to institution
-may lead to medical errors - drug dosing, medication abbreviation
-errors- write error -> cross out with single line, initial, date and time
-no white out

Question 6

SBAR

Answer 6

-tool to facilitate interprofessional communication
-Situation- ex. I am calling because…I have a pt…
-Background- ex. pt was admitted on..because…
-Assessment - ex. i think pt is likely having…
-Recommendations- ex. let us transfer…let us monitor…

Question 7

documenting the clinical encounter

Answer 7

-quality clinical record
-organization- headings, indenting, chronological
-over generalizations- omission of information
-extend of detail- concise and clear, short sentences or phrases
-use of medical terms not lay terms
-describe what you observed or notes on exam
-ex. i examined the eye and saw optic discs vs disc margins sharp
-descriptions or images included
-objective, non judgmental and professional write up

Question 8

documenting on EHR

Answer 8

-EHR vs EMR
-mastery key elements of traditional pt encounter documentation, including familiarity with use of templates and checklists
-comprehensive understanding of key/clinical elements of order entry, including familiarity with use of order sets and pharmacy/prescription entries
-familiarity with medication reconciliation and how/when it must be done
-familiarity with how to access basic laboratory and radiologic data
-familiarity with how to locate and interpret ancillary staff entries including vital sings, inputs/outputs, and nursing/allied health documentation
-ability to locate and review hx data from prior hospitalizations or ambulatory visits including progress notes, admission note, consultation reports, procedure notes, and discharge summaries
-familiarity with how to identify patient demographics including contact information

Question 9

scope of patient assessment

Answer 9

-components of adult health history
-structuring the history of present illness
-structuring the social history including:
-sexual orientation and gender identity
-alcohol use
-tobacco use
-illicit or recreational drugs
-sexual practices
-spirituality
-recording your findings
-modification of the interview for various clinical settings

Question 10

patient assessment: comprehensive or focused

Answer 10

-comprehensive hx
-intital information
-chief complain
-history of present illness
-past medical history
-family hx
-personal and social history
-review of systems
-details of the components of the adult health history

Question 11

focused/problem oriented assessment

Answer 11

-is appropriate for established pts, especially during routine or urgent care visits
-addresses focused concerns or symptoms
-assesses symptoms restricted to a specific body system
-applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible
-problem oriented medical record/problem list
-SOAP- subjective vs. objective data and symptoms vs. sign
-progress note

Question 12

subjective vs objective data

Answer 12

-subjective- CC, HPI, PMH, Family Hx, Personal and social Hx, ROS
-objective- physical exam, lab, test data

Question 13

documentation of HPI

Answer 13

-start with opening statement
-further characterize CC with attention to chronology of events
-then describe accompanying symptoms and their pertinence, called pertinent positive
-include absent symptoms and their pertinence, called pertinent negative*
-add information from other parts of the health history that are relevant

Question 14

mnemonics

Answer 14

-LQQTSMA:
-location
-quality
-quanitity/severity
-timing- onset, duration, frequency
-setting in which it occurred
-modifying factors
-associated manifestations
-OLDCART

Question 15

history and physical exam

Answer 15

-CC
-hx of presenting complaint
-PMH
-medications
-allergies
-family hx
-social hx
-ROS
-physical exam
-assessment and plan

Question 16

review of systems (ROS)

Answer 16

-designed to screen an enormous array of possible problem
-interviewing skill is required to gather data systemically and efficiently without missing important details
-how long does this take
-laundry list
-how do you transition into this step- this is our way of making sure we dont miss something that might be important
-positive responses by pts then need to be followed by more focused questions inquiring about the details of the complaint
-remember that major symptoms discovered during the ROS which may be related to the pts CC (pertinent +) should be moved to the HPI in your write up

Question 17

system to review

Answer 17

-general
-skin
-HEENT
-neck
-breasts
-respiratory system
-cardiovascular system
-peripheral vascular system
-GI
-genitourinary
-musculoskeletal system
-neurologic
-hematologic system
-endocrine system
-psychiatric state

Question 18

psychiatric state

Answer 18

-excessive health care use
-have you felt nervous or tense
-have you had mood changes, depression, or anxiety
-memory changes, suicidal thought or attempts
-were you ever afraid of being hurt at home when you were growing up? What about now?

Question 19

mental status

Answer 19

-medical text vs practice
-how do you write it in your note
-orientation only with statements such as oriented x 3, confused, disoriented
-brief mental status evaluation
-screening questions and observation
-2 validated screening questions for depression: over the past 2 weeks have you felt down, depressed, or hopeless, and over the past 2 weeks have you felt little interest or pleasure in doing things
-if pt seems depressed alaways ask about suicide- have you ever thought about hurting yourself or ending your life
-depression is lethal
-patients with delirium or dementia

Question 20

why should mental status be assessed

Answer 20

-cognitive abnormalities
-25-35% of primary care pts suffer from mental disorders
-complicates their physical illnesses
-legitimizes their complaint
-physical complaints are common

Question 21

oral presentation and documentation

Answer 21

-learning the verbal and written case presentation stand as one of the foundation tasks of medical education
-1. accounting of medical care of pt and provides essential information to other health care providers who will also be caring for the pt
-2. the permanent legal record of the medical care provided to the pt and may be referenced for future care as well as for medico legal purposes
-3. forces clinician to carefully consider the pts health state, to distill and organize the information gathered so as to formulate a coherent assessment of the illness to plan for collaborative management

Question 22

presentation

Answer 22

-Be concise, do not use flowery language when simpler words will do
-Always give the CC
-Do not editorialize (“I think I heard a heart murmur.”) -> Speak decisively
-start physical section with vital signs report
-Clearly state your assessment using opposing descriptors and include your differential and your clinical reasoning
-Summarize appropriately and quantify when possible (post-op day #3 from appendectomy, day #7/10 of levofloxacin for pneumonia).
-Focused summary of all of the details of the patient’s history and illness
-Include pertinent positives and negatives
-Exam and data sections
-Be sure to include your assessment with your differential dx, your reasoning, and your plans for the case

Question 22

oral presentation

Answer 22

-structured, accurate, tailored account of the pt and the pts clinical story
-serves as a primary means of communication between clinicians and the pts other clinical terms
-when done well, oral presentations can improve efficiency of pt care and serve as a forum for group learning
-should also be an expression of your clinical reasoning
-included information should inform the listener about your thinking process and differential dx
-excess data from pt- reduced in write up and further reduced in oral presentation- noncontributory
-guidelines for oral presentation for new pt

Question 23

modifications of interview for various clinical settings

Answer 23

-ambulatory care clinic
-emergency care
-intensive care unit
-nursing home
-home