[01.08b] CMD - Diagnostic Development and SOAP Pt. 2 V2.pdf

10 to 15 percent

What is the commonly cited annual rate of diagnostic errors?

40,000

How many deaths in the United States are potentially caused by diagnostic errors each year?

Clinical expertise, reasoning processes, and decision tools

What three components aid in diagnosis and clinical decision-making?

Old view

Which view of diagnostic errors usually puts the blame on the individual clinician for lack of skill or competency?

New view

Which view of diagnostic errors traces problems in patient safety to breakdowns or gaps in the healthcare system?

No-fault, system-related, and cognitive

What are the three main categories of diagnostic errors?

No-fault error

What type of error occurs when a disease has a masked or unusual presentation?

Patient-related error

How is a diagnostic error classified if the patient is uncooperative or deceptive?

System-related error

What type of error is caused by technical failures or organizational flaws?

Organization, culture, policy, quality system, communication, training, and equipment/reagents

What are the seven components of organizational flaws under system-related errors?

Cognitive error

Which category of error involves a physician's faulty knowledge regarding a disease?

Cognitive error

Which category of error involves faulty data gathering or incorrect synthesis of a patient's presentation?

Cognitive error

Which type of diagnostic error is described as the least forgivable?

Practice style, practice setting, and economic incentives

What are the three primary non-clinical influences on clinical decision-making?

Practice style

Which influence defines the norms of clinical behavior based on a physician’s training and experience?

Defensive medicine

What is the term for using tests with very small marginal benefit to preclude future criticism in case of a bad outcome?

Practice setting

Which factor involves the physical resources available in a doctor’s environment?

Urban tertiary hospital

In what type of setting does a doctor have the benefit of advanced diagnostic and high-tech procedures?

Physician-induced demand

What is the term for the observation that physicians will use medical facilities and technologies once they are available?

Economic incentives

Which non-clinical influence refers to how financial issues exert pressure on decisions?

Fee-for-service

Which physician payment scheme may encourage the overuse of medical interventions?

Capitation

Which payment scheme involves a fixed payment per patient per year regardless of services provided?

Capitation

Which payment scheme encourages doctors to consider a global population budget when managing individuals?

Fixed salary compensation

Which plan pays doctors the same amount regardless of the clinical effort expended?

Fixed salary compensation

Which payment scheme may provide an incentive to see fewer patients?

Checklists

What tool is proposed as a means of reducing cognitive errors in operating rooms and intensive care units?

Electronic medical records

In which digital system is decision support often integrated to minimize errors?

Evidence-based medicine

What is the practice of using various sources of data and knowledge to minimize errors?

Systematic and methodological

What two terms describe the approach diagnosis follows to mirror problem-solving?

Identify the problem

Which problem-solving step corresponds to the chief complaint?

Data collection

Which step in diagnosis development involves the history, physical exam, and additional data?

Accurate presentation of problem

Which step in diagnosis development involves framing?

Formulate hypothesis

Which problem-solving step corresponds to formulating a preliminary diagnosis?

Synthesis of data

What clinical process corresponds to formulating a hypothesis in the problem-solving model?

Develop treatment plan

What corresponds to the problem-solving step of planning ways to test a hypothesis?

Interventions

What corresponds to the implementation step in the diagnosis development model?

Outcomes

What corresponds to the interpretation of results in the diagnosis development model?

General terms or manifestations

How does a patient commonly describe their apparent problem during initial identification?

History and physical examination

What are the two primary components of collecting relevant subjective and objective data?

Cues

What is the term for information provided by the patient?

Inferences

What is the term for the judgments made by the physician based on patient cues?

Accurate presentation of the problem

What is the term for framing a patient's problem as a clinically meaningful representation?

Quantity and quality

What two characteristics of collected data are significant determinants of problem identification?

One-sentence summary

What is used to highlight the defining features of a case during problem presentation?

Who is the patient, temporal pattern, and clinical syndrome

What are the three questions answered by an accurate presentation of a problem?

Ordering and arranging data, assessing significance/prioritizing, and framing

What are the three steps to an accurate presentation of the problem?

Classification

What is another name for ordering and arranging data?

Anatomic, organ-system, pathophysiologic, or a combination

What framework types are used to order and arrange data?

Novice

Which type of clinician must learn to differentiate between relevant and irrelevant cues?

Relationships

What must be determined between data clusters to identify probable causes?

Probabilistic, pragmatic, and prognostic

What are the three approaches used in prioritizing differential diagnoses?

Framing

What cognitive shortcut develops a schema or viewpoint of a situation to represent a problem?

Salient features

Framing involves summarizing the case into what specific features?

Pertinent positives and pertinent negatives

What two types of history and physical findings should be included in the framing summary?

Age, sex, and occupation

What three patient demographics should start the framing of a case?

One line or phrase

How many phrases are allotted for General Data when formulating salient features?

One line or phrase

How many phrases are allotted for the chief complaint in salient features?

One phrase

How many phrases are allotted for relevant details in the HPI and ROS during case formulation?

One phrase

How many phrases are allotted for relevant data in the past medical, personal, social, and family history?

2 to 3 phrases

How many phrases are allotted for relevant data in the physical exam and diagnostic tests?

Primary Impression

What is the clinical term for the working hypothesis or preliminary diagnosis?

Rule out

What term is used in the assessment to indicate a differential diagnosis that needs to be excluded?

Lawrence Weed

Which physician initially defined the Problem-Oriented Medical Record (POMR)?

Concise, complete, and accurate

What are the three results of proper record keeping using the POMR?

Data Base, Completed Problem List, and Initial Plans

What are the three POMR components that must be completed by the admitting physician?

Daily Progress Notes

Which POMR component follows the initial plans?

Final Progress Notes and Discharge Summary

What is the final component of the POMR?

Complete history and physical exam findings

What two items must be included in the POMR Data Base?

Available laboratory or imaging results

What should be included in the initial Data Base if they were obtained during prior consults?

Active or inactive

In what two categories can problems in a problem list be classified?

Active problem

As defined by Weed, what is any problem that requires management or further diagnostic testing?

Inactive problem

How is a past condition, like treated tuberculosis with no symptoms, categorized on a problem list?

Biomedical and psychosocial

What are the two suggested categories for patient problems at the YL7 level?

Biomedical

Which problem category includes primary and secondary diagnoses?

Psychosocial

Which problem category includes stressors at work, school, or in the family?

Psychosocial

Under which category are behaviors needing correction, such as smoking, listed?

Psychosocial

Under which category is a patient's financial capacity to support health needs listed?

Explain the symptoms with a diagnosis

What should a clinician do if they can identify a single disease like pneumonia instead of listing symptoms?

Organize by organ-system or pathophysiology

How should a clinician list problems if they cannot give a definitive diagnosis yet?

Subjective, Objective, Assessment, and Plan

What are the four components of a SOAP note?

Subjective and Objective

Which two parts of a SOAP note review the abnormalities found in the history, PE, and initial labs?

Assessment

Which part of the SOAP note is a pertinent statement of the physician's thoughts on a particular problem?

Diagnostic, Therapeutic, and Patient Education

What are the three distinct groupings required in the Plan section of a SOAP note?

Diagnostic Plan

Which plan includes all the work-up the physician feels is necessary?

Therapeutic Plan

Which plan details initial therapies and their rationale?

Goals of treatment

Besides interventions, what else can be enumerated in a therapeutic plan?

Patient Education Plan

Which plan details how the patient will deal with their problem in the future?

Non-pharmacologic advice

Besides illness education, what other advice is included in the Patient Education Plan?

Data Base

The Subjective and Objective data of a SOAP note correspond to which POMR component?

Completed Problem List

The Assessment portion of SOAP corresponds to which POMR component?

Initial Plans

The SOAP Plan of Management corresponds to which POMR component?

YL7

In which year level are the first three components of the POMR considered core competencies?

Lack of skill or competency

What does the old view of diagnostic errors blame?

Breakdowns or gaps in the system

What does the new view of diagnostic errors blame?

Masked or unusual presentation

What defines a no-fault error regarding disease display?

Organization/standard operating procedures

What is a primary example of an organizational flaw?

Faulty knowledge

What is a primary cause of cognitive errors?

Synthesis

What is the process of putting patient data together to form a diagnosis?

Training and experience

What two factors besides knowledge influence practice style?

Risk of malpractice suit

What perception influences preferred patterns of diagnostic test use?