Scribing

Review of Systems example

-14 organ systems -complete using "negative" or "positive" terms use example: a patient denies chest pain, however reports palpitations ()skipped heart beats say: cardiovascular: positive for palpitations. Negative for chest pain respiratory: positive for cough. Negative for shortness of breath -use "all other systems reviewed are otherwise negative" only if you ask physician

purpose of family history

-Genetic Predisposition -Meet billing and coding requirements -Risk Factors

Why is the medical note important?

-Legal Testimony -Provider Reimbursement -Provider Communicatio

modifying factors terminology

-alleviated/mitigated/improved -exacerbated/aggravated/worsened -provoked -palliated -resolved-used when saying that drugs help

hematological/lymphatic ROS

-anemia -sickle cell/thalassemia -easy bleeding/bruising -history of transfusions -lymphadenopathy: swelling of lymph nodes

hand and wrist

-carpals-bones of the wrist -metacarpals-bones of the palm and back of the hand -phalanges-bones in the fingers -proximal, medial and distal on fingers for bones

spine

-cervical spine (C spine)-neck (7) -thoracic spine-mid back (12) -lumbar spine-low back (5) -sacrum-base of spinal cord. Forms pelvis -coccyx-tailbone

shoulder

-clavicle (collarbone) -scapula (shoulder blade) -acromion (forms highest point of shoulder) -humeral head - joins with the scapula to form the shoulder joint -lacrimal is smallest, most fragile part that forms eye socket area

Chest anatomy

-clavicles, ribs and sternum -protects the heart and lungs -clavicle-collarbone -sternum-breastbone (important in CPR) -ribs-form ribcage

medical note purposes

-communication for providers -legal document -provider and facility reimbursement -research

timing of symptoms terminology

-constant -intermittent-completely resolves at times -waxes and wanes exp: pain that waxes and wanes and is rated an 8/10 at its worst

organ systems list ROS

-constitutional, general -eye -ears, nose, mouth, throat -cardiovascular -respirator -gastrointestinal -genitourinary -musculoskeletal -integumentary (skin and includes breast) -neurologic -psychiatric endocrine -hematologic/lymphatic -allergic/immunologic

skull

-cranium and everything to mandible (jaw) -protects brain -occipital, parietal, temporal, and frontal lobes -sinus area: sphenoid, ethmoid, frontal (forehead), maxillary (cheeks) -nasal bone on nose

terminology of onset of symptoms

-developed exp: patient developed abdominal pain -began exp: pain began one week ago and has persisted -progressive/gradual onset exp: patient developed the progressive/gradual onset of abdominal pain -sudden/acute onset exp: the patient developed the acute onset of abdominal pain

abdomen locations

-epigastric: upper midline of abdomen -periumbilical: mid-midline of the abdomen, near belly button -suprapubic: lower midline of abdomen -RUQ/LUQ/RLQ/LLQ: describe pain in each of 4 quadrants of abdomen

types of patient histories

-family, social, PMHx (past medical history), PSHx (past surgical history) -you can say "no significant history"

genitourinary ROS

-flank pain -burning pain with urination (dysuria) -urinary retention: go to the bathroom and nothing comes out -incontinence: pees accidentally -hematuria (blood in urine) nocturia (urinating at night) -vaginal bleeding -pregnancy: Gravida para abortus, last menstrual period, last normal menstrual period -breast tenderness -erectile dysfunction

endocrine

-goiter -heat or cold intolerance -polydipsia: thirsty -polyuria polyphagia (excessive hunger/appetite)

neurological ROS

-headache -weakness -seizure -paresthesia (pins and needles) -dizziness -confusion -dificulty walking -tremor -parasthesia

family history examples

-health status or causes of death of parents, siblings, or children -specific diseases relating problems identified in CC, HPI, or ROS -use example: A 33 y/o M presents with chest pain and has a family history of early onset heart disease

list of all cardiac risk factors

-history of coronary artery disease (stents, myocardial infarction, heart attack) -hypertension -hyperlipidemia (high cholesterol) -diabetes mellitus -history of tobacco use -famil history of heart disease -history of cocaine or methamphetamine use

PE/DVT risk factors

-hypoxia -tachycardia -unilateral leg swelling -hemoptysis (coughing up blood) -history of previous DVT or PE -recent surgery or trauma -recent periods of immobilization (long car/plane rides, casting, bed rest) -age over 50 -hormone use (birth control included) -pregnancy -cancer

musculoskeletal

-joint pain (arthralgia) -stiffness -muscle pain (myalgia) -muscle cramps/weakness -back pain -decrease range of motion

associated uses in symptoms

-links between two symptoms. Like right shoulder pain associated with numbness in fingers on hand. -NOT something like headache and right leg pain

social history examples

-marital status and/or living arrangements -current employment -occupation history -use of drugs, tobacco, or alcohol -level of education -sexual history use example: a patient that lives alone just had hip replacement surgery and is unable to ambulate for the next few months

severity of symptoms

-mild/moderate/severe -pain scale -quotes "worst pain of my life"

how to document HPI

-must first document how the information was obtained or why something was not obtained -ALWAYS start with name, age of patient and gender. The complaint also follows -then you have the body which can be different between specialty and emergency -

elbow

-olecranon-upper end of the ulna which is the bony process you feel as your elbow tip -epicondyle-rounded projection on a bone. The elbow has two; one on each of the medial and lateral sides

tips for better HPI

-onset, location, context ALWAYS COMES FIRST -type out HPI elements before-hand to do it better

past medical history examples

-past and present medical problems -hypertension (HTN) -diabetis mellitus type II (DMII) -recent admission three days ago for diabetic ketoacidosis (DKA) use example: a patient complaining of shortness of breath has a history of asthma with prior history of intubation

gastrointestinal

-poor appetite -heartburn -nausea -vomiting-coffee ground (dark) or hematemesis (vomiting blood) -Diarrhea-melena (dark tarry stools) Hematochezia (bright red blood) -hemmorhoids

past surgical history examples

-previous surgeries or complications -appendectomy, right breast mastectomy, lumbar fusion use example: a patient complaining of right lower abdominal pain has a history of appendectomy.

lung anatomy

-primary organ for respiration -right and left lung -three lobes on right lung and two on left (heart near here) -bronchus is main passageway to lungs -bronchi-branching off of the primary bronchus to secondary and tertiary bronchi -bronchioles-minute branches which bronchi divide -larynx-voicebox -trachea-windpipe -pleura-membrae that lines the lungs -diaphragm-separates thoracic cavirty from abdominal cavity and aides in respiration

Cardiac and PE/DVT risk factors

-pulmonary embolism/deep vein thrombosis -PERC (pulmonary embolism rule-out criteria) -list these in separate paragraph from HPI

integumentary ROS

-rash -skin changes -pruritis (itching) -laceration

allergic/immunological ROS

-rheumatoid arthritis -HIV -allergies -hay fever

Ears, nose, throat

-ringing in ears (tinnitus) Nose -runny nose (rhinorrhea) congestion nosebleed (epistaxis) MOuth/throat -hoarseness -trouble swallowing (dysphagia)

characteristic quality of symptoms

-sharp, burning, stabbing, dull, achy, throbbing, numbness/tingling, pounding, pulsating, discomfort, heaviness -radiating

respiratory ROS

-sputum: phlegm -hemoptysis: coughing up blood -dyspnea (shortness of breath). At rest or exertion (DOE) -pleuritic pain: chest pain when breathing

more directional terms

-supine: lying flat on back -prone: lying on stomach -supination: rotating the palm face up -pronation: rotate the palm face down, turn inwards -abduction: moving away from body -adduction: moving towards body -flexion: bring closer to origin -extension: move away from origin

foot

-three sections -tarsals: calcaneus-bone that forms the heel -hetatarsals-bones that form the midfoot -phalanges-bones in the toes -hallux-bone of the big toe

ankle

-two joints -true joint: tibia, fibula, and talus -subtalar joint: talus and calcaneus

upper extremity (arm)

-upper arm-humerus -elbow-connects upper arm to forearm. Acts as a hinge to rotate forearm -lower arm-radius and ulna

lower extremity

-upper leg-femur-thighbone -knee-connects femur to tibia and fibula -lower leg-tibia-shinbone and fibula-calf bone

tips for writing HPI

-write in short hand and then go back during downtime to type out each phrase -use a placeholder to flag a medical term that you're unfamiliar with or when unable to properly word a phrase -use alternative identifiers to make writing sound better (the patient/she)

How many vertebrae does the lumbar spine (L Spine) have?

5

Margie McDonald is a 28 y/o F who presents to the ED with lower back pain. She fell yesterday while climbing up some stairs. She states she tripped on her shoelace and landed on her back. The pain radiates to her R leg. Her lower back pain is constant and is worse with movement. Denies numbness or tingling. Denies dysuria or hematuria. She denies any head injury or LOC. How many HPI elements are documented in the HPI sample above?

7 (duration)

Subjective aspects of the medical note

Chief Complaint (CC) History of Present Illness (HPI) Family and Social History (FSHx) Past Medical and Surgical History (PMHx) Medications and Allergies Review of Systems (ROS) Subjective is what a person Says

What is the medical term for collarbone?

Clavicle

Which abdominal region would someone with pancreatitis exhibit pain?

Epigastric

history of abbreviations

H/o

layterms to medical terms

I can't breathe: dyspnea I keep throwing up: emesis I passed out: syncope

first sentence of HPI example

John Smith 44 year old male presents with abdominal pain.

What is the normal sound of a regular heart beat?

Lub Dub

plan and assessment are sometimes called ______ _____ _____ altogether

Medical Decision Making (MDM)

eight elements of HPI

OLD CARTS Onset - yesterday Location - back Duration Character- Aggrevating/Relieving - worse with movement Timing - constant Severity

Objective aspects of the medical note

Physical Exam (PE) Diagnostics: Labs, Radiological Studies and other workups Procedures

Where is the heart's natural pacemaker located?

R Atrium

Which abdominal quadrant is the gallbladder located in?

RUQ

What is the name of the bone(s) that make up the forearm?

Radius and Ulna Correct

What is the anatomical term for shoulder blade?

Scapula

SOAP construction of medical note

Subjective Objective Assessment Plan

History of Present Illness

Subjective (HPI) -retrieve information as provider interviews patient -clear chronological story of what happens -documenting on behalf of the provider who is educated

"my belly hurts" or "I threw up" examples of chief complaints

abdominal pain vomiting

history limited: examples

altered mental state (AMS), Loss of Consciousness (LOC), Intoxicated, poor historian -you can put "limited" but must explain why

directional terms

anterior: in front -posterior: back of the body -cranial: up top -caudal: down -distal: closer to hand/foot -proximal: closer to center of gravity -lateral: going out to the side of a person -medial: going into the side of a person -superior: towards head -inferior: towards feet --superficial: towards body surface -deep: towards the internal part of body

psychiatric ROS

anxiety suicidal sleep deprivation hallucinations

distal

away from the origin of the body part

words to avoid with better alternatives

bad (moderate/severe) better (improved/alleviated) hurt (pain) comes and goes (waxes and wanes) throwing up (emesis/vomit) burns when I pee (dysuria) all the time (constant) stomach (abdomen) pus (purulent) bladder concerns (urinary symptoms) a lot (significant)

inferior

below, towards the feet

anatomical position

body erect feet slightly apart palm face forward thumb point outwards right and left side

superficial

bodysurface

flexion

bring closer to the origin

cardiovascular ROS

chest pain -palpitations -paroxysmal nocturnal dyspnea (PND) increase in intensity at night -orthopnea congestive heart failure

knee

connects upper leg and lower leg -hinge-like motion -patella-knee cap -meniscus-crescent-shaped cartilage pad -cruciate ligaments-ligaments found inside your knee that cross each other and connect the femur to tibia -collateral ligaments: ligaments found on the sides of the knee that control the sideways movement of the knee -posterior cruciate ligament: supports backside of the knee -anterior cruciate ligament: supports the front of the knee

what is a medical note?

document with information regarding patient's visit. serves as document for legal purposes and physician compensation

Both "non-contributory" and no significant past medical history" do NOT count towards the billing requirements for the medial history section.

false

why are histories important?

family history can show patient genetic predisposition -social history can contribute to diseases down the road like from smoking or alcoholic consumption

ribs

first seven are true ribs (connect to spine and sternum) second three are false ribs (connect to lowest true rib) last two are floating ribs (do not connect to anything in front)

heart anatomy

four chambers-two atria and two ventricles -atria-receives body from rest of body -SA node is the pacemaker of the heart -ventricle pushes blood to body and lungs -valves-allow blood to flow in only one direction -aorta-main artery that pumps oxygenated blood to body -pulmonary artery/vein responsible for circulating blood to and from lungs -inferior/superior vena cava-main veins that bring deoxygenated blood back to the heart

abdomen

four quadrants -epigastric, umbilical, suprapubic -Right upper quadrant: liver and gallbladder -left upper quadrant: stomach, spleen, pancreas -right lower quadrant: appendix, right ovaria, right ureter -left lower quadrant: left intestine, left ovary, left ureter

chest locations

midsternal/central left or right sided

additional things to document in medical note

mode of arrival ambulatory/wheelchair/EMS -historian; patient/family/nurse -interpreter used yes/no

adduction

move towards the body

format for listing medications

name, dose, route, schedule Colace 100mg 1 tab PO qHs

allergies

often in same section as medications -have reaction accompany allergen exp: penicillin - hives -if no allergies write NKDA

Assessment

part where patient's symptoms and progress is assessed so the doctor can diagnose. Re-examinations are placed here

history obtained by: examples

patient, parent, family, Emergency Medical Services (EMS), nurse, nurse notes

hip

pelvic girdle-hip -iliac crest-curved, top part of hip bone -sacroiliac joint-sacrum and ilium join -acetabulum-socket where the pelvis and femur meet -ilium-uppermost and largest part of the hip -ischium-lower and back part of the hip -pubic bone-front part of the pelvis

Plan

provider documents plan for the patient -includes disposition: discharge, admit, transfer -physician referrals as well as additional labs ordered. medication prescribed, patient education handed out and follow up

patient abbreviation

pt

Lower Arm

radius and ulna UP. (ulna ontop) -pinky (small finger) is on the same sid as the ulna

HPI differences in body collection

specialty: summarize patient's history, especially if patient has been seen before, and address chief complaint for that day's encounter Emergency/Urgent Care setting: address chief complaint and then the patient history

Chief Complaint

subjective (CC) -why the patient is seeking health care -if patient has more than one then it is the complaint that brought the patient to the doctor -NOT a sentence

medial

towards the middle of the body

Both the hand and feet have phalanges

true

supination

turning the palm upward

eyes ROS

vision changes -sensitivity to light (photophobia) -double vision (diplopia) -glasses/contacts

constitutional ROS

weight loss/gain fever/chills fatigue malaise (generalized weakness)

Interpreter Used examples

yes or no. Language: ____