Week 1 Training Flashcards
subjective vs objective
feeling vs fact, patient vs doctor
pain vs tenderness
patients feeling vs physician’s assessment
bengn
normal nothing of concern
acute vs chronic
new onset vs long standing
baseline
an individual’s normal state of being
auscultation
listening with stethoscope
palpation
the act of pressing on the area by the physcian
inpatient
admitted to the hospital overnight
outpatient
seen and sent home the same day
chief complaint
the main reason for the patients visit
medical decision making
the physician’s thought process
midlevel provider
nurse practitioner or physicians assistant that works under the supervision of the physician to diagnose and treat patients
nurse or medical assistant
records medical histories and symptoms monitors the patient, administers medications and ssists with procedures
receptionist
answeres phone calls shcedules appointments answeres patient questions provides patiens with summary of the vistit and written instuctions from the provider at check out and organizes the patients paper work
scribe
documents the patients visit on the behalf of the physician, access and document lab results and radiology findings, locate and optain PMHx preivious charts and recent studies, record physician interpretations of x rays and EKGs
cannot give orders or touch patients in anyway, participate in care in a way that would effect outcome, authenticate chart or handle specimen
Clinic flow
check in physician evaluation, orders and results, assesment and plan, check out
this stuff follows the format of the chart
H & P
history and physical- part of physician eval. in clinic flow
ARIA
clinics documentation system- electronic medical record (EMR)
SOAP
Subjective, Objective, Assessment and Plan:
Subjective- history of present illness(HPI) and review of systems (ROS)- patient complaint, past history/diagnosis or surgery
Objective- Physical exam (PE) and orders and results- physicians observations and studies
Assessment - diagnoses- short description of progress since last visit
Plan- treatment and follow up for each diagnosis
importance of FHx
history of onset in family helps to determine the genetic risk of a disease for a patient
if the onset of the disease was after 50 y/o the disease is likely due to the environment rather than genetic risk
importance of SHx
this helps determine risks for patients and recommended treatment b/c your aren’t gonna give someone debilitating chemo if they live alone
Tobacco use, alcohol use, illicit drug use, occupation, living circumstance
chief complaint
primary reason patient came in.
must make sure it is detailed so it can be billed properly
ex check up= maintenance visit
follow up= management evaluation
lab results= discuss treatment options(based on results)
medication refill= evaluation of medication management
History of present illness
HPI is the story of the chief complaint so this will be in complete sentence form with proper punctuation and capitalization and approved abbreviations
-symptoms and events that led to the visit that are directly related to the chief complaint
-subjective and is followed throu the rest of chart
-list the complaints of the chief one in the ROS as well
-document their previous symptoms related to this complaint
document any prior testing that is related todays complaint
- structured chronologically (for us)
8 elements of the HPI
element- description
onset- beginning
timing- constant, intermittent or waxing and waning
location
quality- sharp dull aching cramping
severity- mild severe 1-10
modifying factors- what makes it feel worse or better
associated Sx- accompanying symptoms as well as pertinent negatives
context- other important stuff
