Oral and Written Communications

Oral and Written Communications - Oral and Written...

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Oral and Written Communication: (Preparing for Preceptorship) Essentials of Patient Care I October 13, 2010 Melanie Hagen, MD
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The Write Up Progress Note SOAP Note Subjective HPI Past Medical History Social History Family History ROS Objective Physical Exam Assessment Plan
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Remember the Elements of The History Subjective History of Present Illness (HPI) o Includes LOCATES o Includes pertinent positives and negatives Medical History o General state of health o Chronic medical problems o Hospitalizations o Surgical history o History of trauma o Childhood illnesses o Gynecologic history o Health maintenance Medications Allergies Social History o Household, occupation, education, exercise, habits Family History Review of Systems Objective THE PHYSICAL EXAMINATION TESTING RESULTS o Labs/Imaging ASSESSMENT PLAN
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Sign vs. Symptom Symptom Reported by the patient Subjective Pain Itching Stiffness Swelling Sign Observed or measured Objective Tenderness Rash Decreased range of movement Swelling
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Tips for Write Ups: HPI If the patient is unable to give appropriate answers to those questions then document that the patient did not know that particular aspect of his symptom to ensure that you receive credit for asking the question. For example: The patient did not know when the (symptom) started, or how long it lasted. Chronological—with the most recent events first and the less recent events afterwards.
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Tips for Write Up: Past History Remember to get the approximate date/year of onset of the chronic condition. This will help with determining the patient’s risk for complications from long-standing diseases such as diabetes, hypertension, coronary artery disease, COPD and asthma.
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Tips for Write Up: Physical Exam Start with Vital Signs; then General Appearance; then go in head-to-toe order.
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The Head, Eyes, Ears, Nose, and Throat (HEENT) HEENT: Head —The skull is normocephalic/atraumatic (NC/AT). Hair with average texture. Eyes —Visual acuity 20/20 bilaterally. Sclera white, conjunctiva pink. Pupils are 4 mm constricting to 2 mm, equally round and reactive to light and accommodations. Disc margins sharp; no hemorrhages or exudates, no arteriolar narrowing. . Ears: No debris in external auditory canals. Tympanic membranes (TMs) with good cone of light. Nose —Nasal mucosa pink, septum midline; no sinus tenderness. Throat (or Mouth)— Oral mucosa pink, dentition good, pharynx without exudates. Neck —Trachea midline. Neck supple; thyroid isthmus palpable, lobes not felt. Lymph Nodes—No
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Oral and Written Communications - Oral and Written...

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