35 terms

Training Day 5- Assessment and Plan

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Terms in this set (...)

QD
once daily
BID
twice daily
TID
three times daily
Subq
medication injected just under the skin (abbreviation for subcutaneous)
prn
as needed
prognosis
a forecast of the likely course of a disease or ailment
follow-up
on-going with healthcare providers in order to address a health concern
5.1: what is the assessment and what information does it contain?
the assessment included the diagnoses and summary of visit. Before seeing a patient, the doctor typically reviews the assessment from the previous visit. The assessment ALWAYS includes the diagnosis and/or differentials. And may also include:
*brief summary of the HPI
*brief summary of physical exam
*summary of lab/imaging results
*prognosis
T/F: when reviewing a previous visit, the physician is more likely to review the HPI than the assessment because the HPI is more comprehensive.
F
T/F: a diagnosis or differential diagnosis will always be listed in the assessment.
T
What are 3 items besides the diagnosis that may be documented in the assessment?
1. brief summary of the HPI
2. brief summary of physical exam
3. summary of lab/imaging results
4. prognosis
5.2: what are the different ways an assessment can be structured?
simple statement, brief summary, comprehensive summary
simple statement
*age and sex of patient
*past medical history only if relevant
*diagnoses
brief summary
*age and sex of patient
*past medical history, if relevant
*physical exam findings, if relevant
*results, if new and relevant
*diagnoses
*differential, if no definitive diagnosis is found
comprehensive summary
*age and sex of patient
*summary of PMHx
*summary of HPI, including CC, onset and important elements
*summary of PE
*summary of results
*diagnoses
*differential, if applicable
*prognosis, if applicable
T/F: the assessment is typically written in complete sentences.
T
does the assessment always begin with the age and sex of the patient?
yes
What is the structure of a "simple statement" assessment?
*age and sex of patient
*past medical history only if relevant
*diagnoses
Name four items, besides the diagnosis, that are typically included in a comprehensive summary assessment.
1. summary of PE
2. summary of results
3. summary of PMHx
4. summary of HPI, including CC, onset and important elements
5.3: how are results summarized as part of the assessment?
only include results that are new since the last visit. Only include results that are directly related to the patient's diagnosis or differential
Labs
*blood (CBC, chemistry, glucose, lipid panel, etc.)
*urine (urinalysis, pregnancy, drug screen, culture, etc.)
*other (sputum culture, cerebrospinal fluid, STD check, etc.)
Imaging
*X-ray
*CT
*MRI
*Ultrasound
What results are considered pertinent?
*positive results confirming a diagnosis
*negative results that have ruled out a diagnosis
What items are included when summarizing test results?
*name of test
*result of test
*why it was ordered (the differential the test is ruling out of confirming)
T/F: the scribe should only include results that are new since the last visit.
T
a patient visits the clinic with a chief complaint of ankle pain. An XR of the painful ankle is negative for fracture. Does the XR result belong in the assessment? Why or why not?
yes. pertinent negative
A patient with HTN visits the clinic for routine follow-up and routine bloodwork. The physician tells you his diagnosis is "chronic hypertension, well-controlled." Which of the following results belong in his assessment?
normal BP
what three items should you include when summarizing a test result?
*name of test
*result
*why it was ordered
5.4: what information is included in the plan and how is it structured?
The plan is a list outlining how the doctor will treat and/or monitor the patient. The plan appears at the very bottom of the chart and is the last thing documented before the doctor signs the encounter
What information is included in the plan?
*recommended treatment(s) for each diagnosis
*prescriptions ordered today
*studies/tests/labs/imaging ordered today
*follow-up with other healthcare professionals
*follow-up here: when should the patient return for next appt.?
How is the plan written?
*each item should appear on a separate line
*bulleted or numbered list
*at least on bullet/number to address each diagnosis
*last bullet/number should always included the timeline for follow-up in the office
T/F: each diagnosis should be follow-up with at least one line-item in the plan
T
How is the plan formatted?
bullets
The last bullet in the plan should always be ____?
last bullet/number should always included the timeline for follow-up in the office
List three items you may be asked to document in the plan for a patient with a diagnosis of hypertension.
1. Continue taking HCTZ as prescribed
2. Continue BP log
3. Will refill HCTZ today
4. Follow up in 3 months for repeat BP check