Exam 1

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chief complaint

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chief complaint

CC

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quotes

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

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history of present illness

HPI

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SCHOLAR

HPI should use __________ to describe the patient's complaint

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past medical history

PMH

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family history

FH

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first degree

family history should include ____________ relatives only

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social history

SH

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medications

all prescriptions, OTCs, herbals/supplements

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allergies

what is it, and what is the reaction?

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year

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

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review of systems

ROS

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deferred

if ROS not performed, you can document it as ________________

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objective

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

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physical exam

includes pertinent observations and results of organ system tests

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lab tests

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

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serum drug concentrations

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

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diagnostic tests

EKG, X-rays, blood cultures

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problem list

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

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assessment

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

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disease assessment

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

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goals

should be clear, achievable, and measurable

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plan

includes actions needed to resolve the identified problems

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pharmacologic plan

provides a complete description of the drug recommendation

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non-pharmacologic plan

recommendation of lifestyle modifications

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education/counseling

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

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monitoring/follow-up

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

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rationale

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

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inspection

physical exam: general observation of patient

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palpation

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

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percussion

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

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auscultation

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

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head, eyes, ears, nose, throat

HEENT

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journal club

gathering of peers to read and discuss a scientific article together

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harmful incidents

incidents that reach patients and results in actual patient harm

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no harm incidents

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

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near miss

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

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situation

S (SBAR)

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background

B (SBAR)

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assessment

A (SBAR)

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recommendation

R (SBAR)

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