Tags & Description
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)