Week 3 Content

Question 1

Type 1 clinical reasoning and description

Answer 1

intuitive: quick, automatic, involving pattern recognition and matching a patient’s clinical presentation to past experiences

Question 2

Type 2 clinical reasoning and description

Answer 2

analytical: slow and logistical, following steps and an algorithm to make decisions.

Question 3

confirmation bias

Answer 3

you find what you are looking for.

Question 4

____% of your diagosis come from the history

Answer 4

85

Question 5

pertinant positive defined

Answer 5

point TOWARD the diagnosis

Question 6

pertinent negatives defined

Answer 6

point AWAY from the diagnosis

Question 7

child is not able to blow nose until at least what age

Answer 7

4 years: need for suctioning

Question 8

viral syndrome

Answer 8

when young children swallow viral secretions because too young to blow nose

Question 9

working diagnosis

Answer 9

in progress: waiting on lab results etc. to make a confirming diagnosis

Question 10

reasons documentation is needed:

Answer 10

-Record of legal document
-continuity of care
- liability
- a reflection of the bill!
- accurate reflection of the visit
- ability for families to have records of visits
- multi-provider involvement

Question 11

efforts to improve diagnostic reasoning (3) from chiocca

Answer 11

1. lifelong learning
2. peer feedback
3. deliberate practices

Question 12

8 steps of formulating the daignosis

Answer 12

1. history collection
2. analysis of history
3. initial hypothesis
4. objective data (physical exam)
5. analysis of physical exam
6. refinement of hypothesis
   7.further data collection (labs)
7. make a diagnosis

Question 13

acceptable uses of CPCF

Answer 13

1. The author’s previously documented assessment and plan on a given patient that has carried forward to subsequent notes, subject to editing for relevance and accuracy
2. Auto populated, presumably static information (e.g., past medical history and family history) entered by other healthcare providers and carried forward into new documents, subject to confirmation and editing if needed
3. Cumulative, dated information that carries forward to create a running log of daily hospital events
4. Copying and pasting important lists or information (e.g., medication lists), which can prevent potential clinically relevant retyping errors

Question 14

Unacceptable uses of cpcf

Answer 14

1. Copying previous healthcare providers’ documented work (e.g., history, examination, or thought processes) and entering it into a new note unedited (or minimally edited) as if the new author did the work
2. Unedited text carried forward from other notes (including the author’s) that results in conflicting or inaccurate information
3. Unedited or minimally edited notes carried forward from day to day that do not allow readers to determine changes in clinical course

Question 15

abbreviations: Do not use U , use:

Answer 15

Unit

Question 16

abbreviations: Do not use Q.D, qd, qod , use:

Answer 16

daily

Question 17

abbreviations: Do not use 5.0mg, use:

Answer 17

5mg NO TRAILING ZERO

Question 18

abbreviations: Do not use .5mg, use:

Answer 18

0.5 mg ALWAYS HAVE A LEADING ZERO!

Question 19

abbreviations: Do not use , use:

Question 20

abbreviations: Do not use MS , use:

Answer 20

magnesium sulfate OR morphine sulfate

Question 21

Exception of trailing ZERO

Answer 21

Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.

Question 22

SOAP stands for

Answer 22

Subjective data
Objective data
Assessment
Plan

Question 23

“PLAN” part of SOAP includes what three components?

Answer 23

diagnostic, therapeutics and patient education

Question 24

genome relation: married, pregnant, spontaneous abortions, twins, genders, carrier, affected, x linked carrier, deciseased

Answer 24