Subjective Information

CLINICAL VISIT BASICS

  • Review the Clinical Record FIRST!

  • Introductions:

    • Introduce yourself with your name, role, and pronouns.

    • Consider wearing a badge/pin displaying your pronouns.

    • Ask the patient how they would like to be addressed.

    • Avoid assumptions regarding gender and pronouns to prevent bias; instead, ask directly.

  • Hand Hygiene: Perform proper hand hygiene before interacting with the patient.

  • Body Language: Maintain open and positive body language to foster a welcoming environment.

  • Environment: Ensure the clinical environment is conducive to patient-centered care.

  • Patient Centered Care: Approach patient care with the patient's needs and preferences at the forefront.

COMMUNICATION

  • Respectful Communication:

    • Always show empathy and understanding towards the patient's situation.

    • Avoid using spirituality terms that may not resonate with the patient.

    • Refrain from using terms of endearment; maintain professionalism in language.

  • Patient Partnerships: Present yourself as a partner or team member in patient care.

  • Questioning Techniques:

    • Open-ended questions: Encourage discussion rather than yes/no answers.

    • Direct questions: Use when needing specific information.

    • One question at a time: Prevent overwhelming the patient.

    • Active Listening: Indicate attentiveness and engagement by nodding and providing feedback.

  • Space & Silence: Utilize periods of silence to give patients time to think and respond.

  • Avoid Medical Jargon: Use clear, layman's terms to explain medical concepts and procedures.

PRE-ANESTHESIA ENCOUNTER COMPONENTS

  • Subjective Information: information gathered from conversations with the patient about their current health status. EX:

    • Medications the patient is taking

    • Medical diagnosis history such as hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HLD)

    • Details on the timing of the patient's last meal

    • Previous laboratory/test results relevant to the encounter

AANA GUIDELINES: SUBJECTIVE INFORMATION COLLECTION

  • 1) Chief Complaint (CC): A concise (brief) statement identifying the patient's primary reason for needing anesthesia. Try to write down exactly what the patient tells you; don’t substitute anything with medical terminology.

  • 2) History of Present Illness (HPI): A detailed paragraph elaborating on the chief complaint, should include the 7 Attributes of a Symptom

    • OLD CARTS: Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation/relieving factors, Timing, Severity

3) Review of Systems (ROS)

  • Definition: Documentation capturing the presence or absence of common symptoms across various body systems.

    • Pertinent Positive — Presence of a symptom that supports a diagnosis (e.g., anorexia in appendicitis) and Pertinent Negatives — Absence of a symptom that helps rule out a diagnosis (e.g., no fever in a patient with abdominal pain makes infection less likely)

  • 14 Body Systems Recognized: Constitutional, Head, Eyes, Ears, Nose, Throat (HEENT), Cardiovascular (CV), Respiratory (Resp), Gastrointestinal (GI), Genitourinary (GU), Musculoskeletal (MSK), Integumentary (divided into Skin and Breast), Neurological (Neuro), Psychiatric (Psych), Endocrine, Hematologic/Lymphatic, Allergic/Immunologic

  • ROS Coverage Required by AANA:

    • Cardiovascular (CV)

    • Respiratory (Resp)

    • Gastrointestinal (GI)

    • Neurological (Neuro)

    • Musculoskeletal (MSK)

    • Genitourinary (GU)

    • Psychiatric (Psych)

      • NOT SKIN?!

4) Past, Family, and Social History (PFSH)

  • Medical History:

    • Identify comorbidities and disabilities present.

    • Note any dental considerations such as dentures, partials, retainers, contacts, glasses, or prosthetics.

    • Document breastfeeding status and relevant allergies (food, drug, environmental).

      • Distinctly differentiate between an allergy (immune response, e.g., hives/anaphylaxis) and a side effect (e.g., nausea from codeine). Document the specific reaction.

    • Immunization status is essential to note.

    • List current medications, including: Name of the medication, Dosage, Route (e.g., oral, injection), Frequency of administration, and Last administration date and time

      • Include compliance, OTC, and herbal supplements

  •     Surgical History:

    • Include details on surgical procedures:

    • Procedures performed

    • Dates of procedures

    • Any adverse reactions to anesthesia encountered

Additional Historical Factors

  • Transfusion History

  • Hospitalizations

  • Social History: Gather information about alcohol (ETOH) use, tobacco use, and recreational or illicit drug use.

    • Tobacco: Quantify in pack-years (packs per day×years smoked).

    • CAGE Questionnaire: Cut down, Annoyed by criticism, Guilty, Eye-opener. Two or more "yes" answers suggest alcohol use disorder.

    • AUDIT-C: Now preferred over CAGE for identifying hazardous drinkers before they reach dependence

  •     Note marital status and number of children.

    • Ask if they feel safe at home and their sexual orientation, including sexual activities they engage in.

      • Sexual History (5 Ps): Partners, Practices, Protection from STIs, Past history of STIs, Pregnancy plans (Plus: Trauma/Violence)

    • Consider health maintenance activities such as exercise, diet, immunizations, and routine screenings (e.g., colonoscopy, mammogram, dental cleanings).

  • Advanced Directive/Code Status

  • NPO Status (Nil Per Os)

  • Family History: A three-generation pedigree may be required (e.g., siblings, children, great-grandparents, aunts, uncles, cousins. NOT your SO.

    • Document any family history of smoking and other health concerns.

TEXTBOOK INFORMATION

  • Disease: The clinician’s explanation/organization of symptoms leading to a diagnosis (biomedical perspective).

  • Illness: The patient’s experience of the disease (effects on relationships, function, and well-being)

  • What is the correct terminology when referring to a patient based on the anatomical parts they were born with? SEX

  • What is the correct terminology for the socially constructed classification that the patient identifies with? GENDER

  • What is the importance of SDOH? PROVIDES HOLISTIC CARE FOR INDIVIDUALS IMPACTED BY HEALTH INEQUITIES. IMPROVES OVERALL HEALTH AND WELLBEING OF PATIENTS.

  • What is subjective information? Information that the patient tells you about their health history -OR- health history items that you can review in the patient chart from previous encounters.

  • The SOAP Note — "If it isn't documented, it didn't happen".

    • S - Subjective: What the patient (or family/chart) tells you. Includes CC, HPI, ROS, PFSH.

      • Pearl: "left arm numbness" is subjective

    • O - Objective: What you observe; Includes Vital Signs, Physical Exam, and resulted Labs/Imaging. Interventions done during the visit (e.g., giving a knee immobilizer) are documented under Objective.

      • Pearl: "Decreased sensation to pinprick in left arm" is objective

    • A - Assessment: The diagnosis or differential diagnosis (DDx).

      • Rule: Do not document a "rule out" diagnosis as confirmed (e.g., do not code for "pneumonia" if it is only suspected; code the symptom "cough")

      • DDx Order: List from most likely to least likely, or most severe to least severe.

    • P - Plan: Diagnostics ordered, Therapeutics (meds), Education, Referral, Follow-up.