9-15-09 - Understanding the Medical Chart picture Admitting...

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Unformatted text preview: Understanding the Medical Chart picture Admitting Note • Identifying Data • Chief Complaint • Past Medical History • Family History • Social History • Patient Habits • Psychological History • Systems Review Identifying Data • Name • Address • SSN (social security number) or Medical Record # • Age/DOB (date of birth) • Race • Body Build • Occupation • Other • Insurance information Chief Complaint • “What brings you here today?” • Patient is asked about • Pain • ADL • Disability • Insurance won’t approve of treatment if you can do ADLs History of Past Illnesses • Ask patients to list any past diagnoses and treatments • Hospitalizations? • Past surgeries? • Include dates; appropriate dates Family History • Some illnesses have a hereditary factor • For example: • Diabetes Mellitus • Cancer (ex. – breast cancer) • Heart Disease Patients Habits/Social History • Daily Living • Work History • Alcohol use • Smoking • Eating Habits • Drug use • Over the counter/Prescription • Illegal Psychological History • History of psych diagnosis? • Trouble adjusting to illness • Ability to follow directions • Alert and oriented? • Memory problems? • Will affect how we plan their program Systems Review • The patient is questioned about other possible symptoms so that other problems can be recognized • Cardiovascular : short of breath, chest pain. Palpitations • Respiratory: cough, secretions • Neurological : numbness, weakness, fainting • Musculoskeletal : pain, deformity, stiffness The Physical Exam – Comes after the questions Purpose of Physical Exam • To gather information that will be used to diagnose patient problems • To note any secondary diagnoses • To assess residual strengths in systems – if a patient has a massive (huge) stroke, the other side of the body is still strong General Appearance • Body composition: WD (well-developed), WN (well- nourished), Obese, Morbidly Obese, Cachectic (excessively thin – looks like they are wasting away like an AIDs patient or someone who has cancer), Thin • Cooperation • Motivation • Cleanliness • Alert? Integumentary System • Skin system • Decubitus ulcers • Scars • Contractures – often due to a burn; shortening of a structure that causes a decrease in ROM; treatment is to gradually stretch out the structure • Rashes • Bruises • Discolorations • Open wounds and drainage • Color of skin – if the color is good or bluish which means not enough oxygen HEENT • Head, Eyes, Ears, Nose and Throat • Hearing • Vision • Teeth, gums, tongue • Ability to chew and swallow • Check for bleeding • Deviated septum • Etc. Cardiovascular System • Heart rate • Blood pressure • Pulses • (carotid, radial, other) • Pedal edema – swelling of the feet due to an accumulation of fluid; see this in patients with heart failure • Listen to heart • (auscultation) • Check fingertips – check color of fingertips to determine if good blood circulation • Skin temperature – indicates blood circulation to whole body Respiratory System •...
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9-15-09 - Understanding the Medical Chart picture Admitting...

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