Exam 1

chief complaint

CC

quotes

chief complaint should utilize ____________ in the patient's own words.

history of present illness

HPI

SCHOLAR

HPI should use __________ to describe the patient's complaint

past medical history

PMH

family history

FH

first degree

family history should include ____________ relatives only

social history

SH

medications

all prescriptions, OTCs, herbals/supplements

allergies

what is it, and what is the reaction?

year

include immunizations the patient has received and the _________ it was given

review of systems

ROS

deferred

if ROS not performed, you can document it as ________________

objective

data obtained by the clinician, EMR, lab work, or diagnostic tests; can be measured

physical exam

includes pertinent observations and results of organ system tests

lab tests

often compared to previous values to show trends of increasing or decreasing values

serum drug concentrations

includes results for drugs that require blood monitoring such as vancomycin, phenytoin, and valproic acid

diagnostic tests

EKG, X-rays, blood cultures

problem list

issues prioritized by importance; includes all medical issues including controlled ones

assessment

outlines what the practitioner thinks the patient's problem is based on subjective and objective information

disease assessment

often includes severity or current status of a disease state; evidence of thinking

goals

should be clear, achievable, and measurable

plan

includes actions needed to resolve the identified problems

pharmacologic plan

provides a complete description of the drug recommendation

non-pharmacologic plan

recommendation of lifestyle modifications

education/counseling

briefly mention the most important points that should be communicated to the patient for each problem

monitoring/follow-up

Include what is to be measured, how often, and where the patient should go to have this measured

rationale

discuss your thought process for the treatment choice; reference disease state guidelines and mechanism of action of med

inspection

physical exam: general observation of patient

palpation

physical exam: use of sense of touch in evaluation of patient

percussion

physical exam: used to produce sounds, elicit tenderness, or assess reflexes in a patient

auscultation

physical exam: involves listening for normal and abnormal sounds with a stethoscope

head, eyes, ears, nose, throat

HEENT

journal club

gathering of peers to read and discuss a scientific article together

harmful incidents

incidents that reach patients and results in actual patient harm

no harm incidents

reaches a patient but does not cause any observable or measurable harm

near miss

incident that may have caused harm but did not reach the patient

situation

S (SBAR)

background

B (SBAR)

assessment

A (SBAR)

recommendation

R (SBAR)