Study Aid: MICS Medical Note Quiz

What is the purpose of using a standardized note format?

Conveys complete information

Conveys information in an order other providers are expecting

Helps guide diagnostic thinking process

Legal record of your encounter with the patient

What is a "chief complaint" or "chief concern"?

One-line opening statement

Contains the ONE major presenting concern/syndrome and duration

Answers, "What brings you in today?"

What does OPQRST stand for?

◼ Onset

◼ Provocative and Palliative factors

◼ Quality

◼ Region and Radiation

◼ Severity

◼ Timing

OPQRST:

Commencement

Gradual vs Sudden

"After eating"

"After living heavy object"

Acute vs recurrent

Onset

OPQRST:

What makes the pain better or worse?

Common measures or triggers?

Provocative/Palliative

OPQRST:

Sharp

Burning

Aching

Bilious vomitous

Spinning sensation

Tea-colored Urine

Quality

OPQRST:

Location-be specific!

Does the pain travel?

Region/Radiation

OPQRST:

Scale of 1-10

Mild, moderate, severe

Ex. Dyspnea so bad I couldn't climb a set of stairs

Severity

OPQRST:

Intermittent

Constant

Morning, Afternoon, Evening

Fall, Winter, Spring, Summer

Timing/Time Course

Consists of:

1. Opening Sentence

2. Analysis Review of all relevant signs/symptoms (OPQRST)

3. Full picture (Chief Complaint plus details)

History of Present Illness

Will most likely come from your ROS

Symptoms or signs that you would expect to find if a possible cause for a patient's problem were true, which then supports this diagnosis.

These are recorded in the HPI (as well as your ROS section)

Pertinent Positive

S/Sx which are absent and therefore help rule out causes considered for the presentation (rule out causes on your ddx)

S/Sx which are absent but which usually are positive in patients presenting with the diagnosis you most strongly suspect.

These are listed at the end of the HPI but made clearly distinct.

Pertinent Negatives

Complete Sequence of the H&P Note:

○ Chief Complaint

○ History of Present Illness

○ Review of Systems (ROS)

○ Past Medical History

○ Family history

○ Psychosocial history

○ Medications

○ Allergies

○ Physical Exam

○ Labs and diagnostic

test results

○ MDM

○ Assessment and Plan

Contains the following:

○ Age

○ Race

○ Gender

○ Chronic adult illnesses or health status, particularly if relevant

○ Setting of care and manner of presentation (Family practice, ED, EMS, police escort, etc.)

○ Reason for visit ( EXACT re-statement of chief complaint)

Proper Opening Sentence

Ex.

○ 57 y/o AAM with PMHx of HLD x 10y, HTN x 5y, and CAD x 2y who presents to the ED via EMS c/o chest pain x 2 hrs.

The components of proper documentation of a medication

○ Medication name

○ Dosage (include units)

○ Route (PO vs IM vs INJ vs INH vs intranasal)

○ Frequency (PRN or scheduled?)

○ Indication

What part of a note needs to in narrative form?

Psychosocial Documentation

Documentation of allergies need to include:

Includes ALL known allergies (Medication , Latex, Food ,Seasonal/Environmental)

Ask about each category - don't just ask "do you have any allergies?"

Listed in a bullet point format

List the reaction ( Is it a true allergy, or is it a side effect or intolerance)

Which part of ROS:

● Weight change ○ loss/gain

● Fever/chills

● Fatigue

● Weakness

● Weakness

● Night sweats

● Malaise

Constitutional

Which part of ROS:

● Changes in texture, or appearance of hair, skin, or nails

● Cyanosis or Pallor

● Rashes or lesions or bruises

● Dry Skin

● Jaundice (yellowing)

● Pruritus

Integumentary

Which part of ROS:

● Recent change in vision

● Blurry vision

● Spots/floaters

● Flashing lights

● Diplopia

● Red, jaundiced, or painful eyes

● Discharge/drainage

● Increased lacrimation

Eyes

Which part of ROS:

◼ Change in hearing, otalgia, otorrhea

◼ Tinnitus or vertigo

◼ Rhinorrhea (color, consistency), epistaxis

◼ Facial pain

◼ Post nasal drip

◼ Anosmia

◼ Dental pain, bleeding or swelling of gums

◼ Ulcers or lesions of tongue, teeth, gums, or mouth; dentures

◼ Sore throat, hoarseness, or voice change

Ears, Nose, Mouth, and Throat

Which part of ROS:

● Tenderness

● Masses or deformity

● Nipple discharge

● Changes in nipple or skin

Breasts

Which part of ROS:

● Cough

● Sputum production

● Hemoptysis

● Wheezing

● Dyspnea

● Pleurisy

Respiratory

Which part of ROS:

● Chest pain

● Palpitations

● Dyspnea on exertion (DOE)

● Diaphoresis

● Orthopnea

● Paroxysmal nocturnal dyspnea (PND)

● Pedal edema

● Claudication

● sensitivity or distal color change with exposure to cold

● leg pain or leg cramps

● erythema, or swelling

● ulceration or temperature change of extremities

● hair loss

Cardiovascular

Which part of ROS:

○ Dysphagia, odynophagia

○ Change in appetite/anorexia

○ Nausea, vomiting

○ Abdominal pain

○ Hematochezia or melena

○ Constipation or diarrhea

○ Change in bowel habits or stool appearance

○ Jaundice

○ Dyspepsia/indigestion, new food intolerance

○ Excessive belching or passage of flatus

Gastrointestinal

Which part of ROS:

● Change in frequency, volume, or nature of urination

● Dysuria, hematuria

● Nocturia (how many times per night?)

● Hesitancy or urgency

● Incontinence

● Flank or suprapubic pain

Genitourinary

Which part of ROS:

● Bleeding between menses or after intercourse

● Dysmenorrhea

● Dyspareunia

● Post-menopausal bleeding

● Vaginal discharge/pruritus

● Vulvar lesions/pruritus/pain

● Changes in sexual drive, sexual satisfaction or concerns

Genitourinary Female

Which part of ROS:

● Groin/thigh swelling or mass

● Penile lesions or discharge

● Testicular pain/masses

● Ability to achieve and maintain erection ● Ability to ejaculate

● Changes in sexual drive, sexual satisfaction or concerns

Genitourinary Male

Which part of ROS:

● Muscle weakness

● Myalgias

● Arthralgia

● Joint stiffness

● Joint swelling

● Neck or back pain

Musculoskeletal

Which part of ROS:

● Headaches

● Seizures

● Blackouts, syncope, or lightheadedness ● Dizziness

● Paralysis

● Anesthesia or paresthesias

● Tremors or other involuntary movement ● Weakness

● Muscle atrophy

● Difficulty speaking

● Memory loss, difficulty concentrating

Neurologic

Which part of ROS:

○ Weight gain or loss

○ Heat or cold intolerance

○ Hair, skin, or nail changes

○ Diarrhea or constipation

○ Palpitations

○ Polydipsia, polyphagia, or polyuria

Endocrine

Which part of ROS:

○Easy bruising or difficulty controlling bleeding

○ Tenderness or enlargement of lymph nodes (neck, axillae, or groin areas)

○ Unilateral limb edema

Hematologic/Lymphatic

Which part of ROS:

○ Atopy

○ Pet or food allergies

○ Frequent or chronic infections

○ Poor healing

○ Angioedema

Allergic/Immunologic

Which part of ROS:

● Insomnia/hypersomnia

● Sleep disruptions

● Disorientation

● Memory loss

● Change in ability to concentrate

● Excessive nervousness or crying

● Mood extremes

● Depressed mood

● Hallucinations

● Suicidal or homicidal ideations

Psychiatric

Consists of the following Components:

● Childhood Illnesses

● Adult Illnesses

● OBGYN history (Menstrual History, Sexual / Contraception History, Obstetrical History)

● Psychiatric history

● Accidents and Injuries

● Hospitalizations

● Surgical History

● Immunization history

● Screening Tests / Health Maintenance

Past Medical History

Consists of the following Components:

● Ethnic lineage

● Support systems

● Home situation / significant others

● Daily life

● Occupational history

● Financial situation

● Education

● Military history

● Other significant life events

● Travel

● Sleep

● Exercise / leisure activities

● Safety Measures

● Effect of Illness

● Diet

● Tobacco

● Alcohol

● Marijuana

● Illicit drug use

●Sexual History

Psychosocial Documentation

A 10 points scale is useful for documenting the severity of pain, but how might you document the severity of dyspnea?

"Cannot climb a set of stairs"

What is the purpose of the MDM section?

A narrative which provides the clinical reasoning for "why you did what you did"

The backbone of every patient encounter

Consists of:

○ Problems addressed

○ Complexity of data

○ Risks of patient management

What are the 4 components for the plan for each item listed in the assessment? (e.g. dx, etc)

○ Diagnostics

○ Therapeutics

○ Patient Education/Supportive Care

○ Disposition

What do the sections of a SOAP note consist of and which of the complete medical note components would be an "S" versus an "O"?