C C 306M Chapter 2 Notes.docx

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Classical civilization
C C 306M
Todd Curtis

Chapter 2: Health Care Records The History and Physical History and physical (H&P) – documents the patient’s medical history and findings from the physical examination  Recorded at a new patient visit or as part of a consultation  Usually the first document generated when a patient presents for care First portion: history (Hx)  Documents subjective information from patient’s personal statement about his or her medical history  Begins with chief complaint (CC) *patient’s reason for seeking medical care] o Usually brief o Recorded in patient’s own words indicated by quotation marks  Then present illness (PI) or history of present illness (HPI) o Noting the duration and severity of the complaint o Notations about the patient’s symptoms (Sx)  Subjective evidence  Then patient’s past history (PH) or past medical history (PMH) o Patient’s past illnesses starting with childhood o Includes surgical operations, injuries, medications, physical defects and allergies  Then family history (FH) o Include state of health of immediate family members  Then social history (SH) o Patient’s recreational interests, hobbies, use of tobacco and drugs (even alcohol)  Then occupational history (OH) o Record of work habits that may involve health risks  Lastly review of systems (ROS) or a systems review (SR) o Head-to-toe review of the functions of all body systems Second portion: physical examination (PE) or a physical (Px)  Objective information [facts that can be seen or detected by testing] o Signs are documented and diagnostic test are performed  HEENT (head, eyes, ears, nose and throat)  PERRLA (pupils equal, round, reactive to light and accommodation)  NAD (no acute distress)  WNL (within normal limits)  Impression (IMP), diagnosis (Dx) or assessment (A) o Identification of a disease or condition is recorded  Differential diagnosis – when there are one or more diagnoses in question, this diagnosis is made o Further investigation to rule out each suspect to get the final diagnosis  Health care provider’s plan (P) o Also called recommendation or disposition o Final notations from the health care provider  outlines strategies designed to remedy the patient’s condition Often, physicians are required to dictate a current H&P before admitting a patient to the hospital  preoperative H&P Progress Notes These notes are used to document the patient’s continued care; uses SOAP method  S = subjective [that which the patient describes]  O = objective [observable information]  A = assessment *patient’s progress and evaluation of the plan’s effectiveness  P = plan [decision to proceed or to alter the plan strategy] Chapter 2: Health Care Records Hospital Records Many different records:  History and physical  Physician’s orders  Nurse’s notes  Physician’s progress notes  Consultation report  Operative report [if surgical remedy is indicated] o Detailed account of the operation is given o Method of incision, technique, instruments used, types of sutures, method of closure and patient’s response during the procedure  Anesthesiologist’s report o Drugs used, dose and time given, and the patient’s vital status throughout the procedure  Informed consent o Must be signed by the patient to show he or she has been advised of the risks and benefits of the proposed treatment as well as alternatives  Ancillary reports o Notes any additional procedures and therapies including  Diagnostic tests  Pathology reports  Discharge summary o Also termed clinical resume, clinical summary or discharge abstract o Summary of the patient’s hospital care  Including date of admission, diagnosis, course of treatment, final diagnosis and date of discharge Common Diagnostic Tests and Procedures Methods of diagnostic imaging have rapidly expanded since Wilhelm Roentgen discovered x-rays in 1885! Ionizing – a process that changes the electrical charge of atoms and has a possible effect on body cells Ionizing Imaging:  Radiography (X-ray) o An imaging modality that uses x-rays (ionizing radiation) to produce images of the body’s anatomy for the diagnosis of a condition or impairment o Small amount of radiation is passed through the body to expose a sensitive film  Called radiograph  Computer tomography (CT) or computed axial tomography (CAT) o Uses a machine (scanner) to examine a body site by taking a series of cross-sectional x-ray films in a full- circle rotation o Computer then calculates and converts the rates of absorption and
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