DOCSLIB.ORG

Chief Complaint: History of Illness

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Chief Complaint: History of Illness Pain Management Center HEALTH ASSESSMENT Pain Management Center Page 4 of 4 HEALTH ASSESSMENT Page 1 of 4 Review of Symptoms: Headache YES NO Diarrhea YES NO DATE: Palpitations YES NO Bladder/Bowel YES NO NAME: DOB: Chronic Cough YES NO Incontinence YES NO REFERRING MD: PRIMARY MD: Heartburn YES NO Heat Tolerance YES NO ADDRESS: ADDRESS: Blood in Urine YES NO Weakness YES NO Thrist/Polyuria YES NO Shortness of Breath YES NO Visual Problems YES NO Constipation YES NO PHONE: PHONE: Chest Pain YES NO Swelling YES NO Chief Complaint: Wheezing YES NO Other YES NO Please briefly state the main reason you are here today. For example: low back pain, headache, right shoulder pain, etc. This is the end of the patient section, the rest of the information will be filled in by your doctor or nurse. History of Illness: Patient Signature: Date: When did the pain first start? Pre-Procedure Evaluation How did your pain start? History of present Illness: Was it the result of an accident or injury? YES NO Are you involved in litigation (a lawsuit?) YES NO Is Worker’s Compensation involved in your injury? YES NO Does the pain radiate from this part of your body to another area? If yes, where? Please check the words that best describe your pain: BP: Pulse: Ht: Wt: VNS: ACHING HOT SHOOTING SHARP COLD NAGGING Physical Exam: BURNING NUMB SEVERE STABBING TINGLING OTHER: Airways: Lung: Heart: ASA: Please indicate on the chart where your pain is: Musculoskeletal: Neurological: Diagnosis: Plan of Procedure: CL0300 FRONT BACK LEFT SIDE RIGHT SIDE Please circle the number on the scale of 0 - 10 that represents your pain: 0 1 2 3 4 5 6 7 8 9 10 no pain severe pain X , MD _____/_____/_____ ___ ___ : ___ ___ PC 007 10/12 Signature Pager # Date Time Pain Management Center Pain Management Center HEALTH ASSESSMENT HEALTH ASSESSMENT Page 2 of 4 Page 3 of 4 Date: Date: Is your pain constant or intermittent? Constant Intermittent Past Medical History: If your pain is intermittent, is there a time of day when your pain is usually worse or better? Do you have history of any of the following? Worse AM/PM Better AM/PM Chest Pain YES NO Stroke YES NO Are there activities which make your pain worse (example: walking, sitting, stair climbing, etc.)? Heart Attack YES NO Ulcer Disease YES NO High Blood Pressure YES NO Diabetes YES NO What makes your pain better? Congestive Heart Failure YES NO Thyroid Problem YES NO Abnormal Heart Rhythm YES NO Anemia YES NO Asthma YES NO Bleeding Disorders YES NO Please check any diagnositc tests you have had for this condition: Pneumonia YES NO Arthritis YES NO MRI CAT SCAN EMG OTHER: Kidney Failure YES NO Psychiatric Disorder YES NO Please check any treatment you have had for pain: Prostate Trouble YES NO Cancer YES NO Liver Failure YES NO HIV YES NO ACUPUNCTURE NERVE BLOCK or other STEROID INJECTIONS Hepatitis YES NO Are You Pregnant YES NO CHIROPRACTOR PHYSICAL / AQUA THERAPY Seizure YES NO HEAT / COLD SURGERY MASSAGE TENS Past Surgical History: MEDICATIONS OTHER: Check this box if you have never had surgery. Please list any surgical procedures that you have had and the date of surgery Current Medications: Surgery: Date of operation: All other medications not for pain. Medication: Amount (mg.) Frequency What is it for? Family History: Please list any diseases that run in your family, for example; diabetes, heart disease, cancer, etc. Pain Medications: Please list any pain medications you are taking now or have in the past to treat your pain. Medication: Amount Has it Helped? Prescribed by: Social History: YES NO Do you smoke? YES NO If so how much? YES NO Do you drink alcohol YES NO If so how much? YES NO CL0300 Have you ever had a problem with alcoholism? YES NO Do you have any history of using Marijuana, Cocaine, Heroin, or any other illegal drugs? YES NO YES NO CL0300 If yes which drugs? YES NO Marital Status: single married divorced widowed committed relationship Allergies: Work Status: working not working retired disabled Check this box if you have no known drug allergies. Disability: temporary permanent Please list any medications that you are allergic to and the adverse reaction you have. Reason for disability: Medication: Adverse reaction Pain Management Center Pain Management Center HEALTH ASSESSMENT HEALTH ASSESSMENT Page 2 of 4 Page 3 of 4 Date: Date: Is your pain constant or intermittent? Constant Intermittent Past Medical History: If your pain is intermittent, is there a time of day when your pain is usually worse or better? Do you have history of any of the following? Worse AM/PM Better AM/PM Chest Pain YES NO Stroke YES NO Are there activities which make your pain worse (example: walking, sitting, stair climbing, etc.)? Heart Attack YES NO Ulcer Disease YES NO High Blood Pressure YES NO Diabetes YES NO What makes your pain better? Congestive Heart Failure YES NO Thyroid Problem YES NO Abnormal Heart Rhythm YES NO Anemia YES NO Asthma YES NO Bleeding Disorders YES NO Please check any diagnositc tests you have had for this condition: Pneumonia YES NO Arthritis YES NO MRI CAT SCAN EMG OTHER: Kidney Failure YES NO Psychiatric Disorder YES NO Please check any treatment you have had for pain: Prostate Trouble YES NO Cancer YES NO Liver Failure YES NO HIV YES NO ACUPUNCTURE NERVE BLOCK or other STEROID INJECTIONS Hepatitis YES NO Are You Pregnant YES NO CHIROPRACTOR PHYSICAL / AQUA THERAPY Seizure YES NO HEAT / COLD SURGERY MASSAGE TENS Past Surgical History: MEDICATIONS OTHER: Check this box if you have never had surgery. Please list any surgical procedures that you have had and the date of surgery Current Medications: Surgery: Date of operation: All other medications not for pain. Medication: Amount (mg.) Frequency What is it for? Family History: Please list any diseases that run in your family, for example; diabetes, heart disease, cancer, etc. Pain Medications: Please list any pain medications you are taking now or have in the past to treat your pain. Medication: Amount Has it Helped? Prescribed by: Social History: YES NO Do you smoke? YES NO If so how much? YES NO Do you drink alcohol YES NO If so how much? YES NO CL0300 Have you ever had a problem with alcoholism? YES NO Do you have any history of using Marijuana, Cocaine, Heroin, or any other illegal drugs? YES NO YES NO CL0300 If yes which drugs? YES NO Marital Status: single married divorced widowed committed relationship Allergies: Work Status: working not working retired disabled Check this box if you have no known drug allergies. Disability: temporary permanent Please list any medications that you are allergic to and the adverse reaction you have. Reason for disability: Medication: Adverse reaction Pain Management Center HEALTH ASSESSMENT Pain Management Center Page 4 of 4 HEALTH ASSESSMENT Page 1 of 4 Review of Symptoms: Headache YES NO Diarrhea YES NO DATE: Palpitations YES NO Bladder/Bowel YES NO NAME: DOB: Chronic Cough YES NO Incontinence YES NO REFERRING MD: PRIMARY MD: Heartburn YES NO Heat Tolerance YES NO ADDRESS: ADDRESS: Blood in Urine YES NO Weakness YES NO Thrist/Polyuria YES NO Shortness of Breath YES NO Visual Problems YES NO Constipation YES NO PHONE: PHONE: Chest Pain YES NO Swelling YES NO Chief Complaint: Wheezing YES NO Other YES NO Please briefly state the main reason you are here today. For example: low back pain, headache, right shoulder pain, etc. This is the end of the patient section, the rest of the information will be filled in by your doctor or nurse. History of Illness: Patient Signature: Date: When did the pain first start? Pre-Procedure Evaluation How did your pain start? History of present Illness: Was it the result of an accident or injury? YES NO Are you involved in litigation (a lawsuit?) YES NO Is Worker’s Compensation involved in your injury? YES NO Does the pain radiate from this part of your body to another area? If yes, where? Please check the words that best describe your pain: BP: Pulse: Ht: Wt: VNS: ACHING HOT SHOOTING SHARP COLD NAGGING Physical Exam: BURNING NUMB SEVERE STABBING TINGLING OTHER: Airways: Lung: Heart: ASA: Please indicate on the chart where your pain is: Musculoskeletal: Neurological: Diagnosis: Plan of Procedure: CL0300 FRONT BACK LEFT SIDE RIGHT SIDE Please circle the number on the scale of 0 - 10 that represents your pain: 0 1 2 3 4 5 6 7 8 9 10 no pain severe pain X , MD _____/_____/_____ ___ ___ : ___ ___ PC 007 10/12 Signature Pager # Date Time.
Load more

Recommended publications
  • Advanced Interpretation of Adult Vital Signs in Trauma William D
    Advanced Interpretation of Adult Vital Signs in Trauma William D. Hampton, DO Emergency Physician 26 March 2015 Learning Objectives 1. Better understand vital signs for what they can tell you (and what they can’t) in the assessment of a trauma patient. 2. Appreciate best practices in obtaining accurate vital signs in trauma patients. 3. Learn what teaching about vital signs is evidence-based and what is not. 4. Explain the importance of vital signs to more accurately triage, diagnose, and confidently disposition our trauma patients. 5. Apply the monitoring (and manipulation of) vital signs to better resuscitate trauma patients. Disclosure Statement • Faculty/Presenters/Authors/Content Reviewers/Planners disclose no conflict of interest relative to this educational activity. Successful Completion • To successfully complete this course, participants must attend the entire event and complete/submit the evaluation at the end of the session. • Society of Trauma Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Vital Signs Vital Signs Philosophy: “View vital signs as compensatory to the illness/complaint as opposed to primary.” Crowe, Donald MD. “Vital Sign Rant.” EMRAP: Emergency Medicine Reviews and Perspectives. February, 2010. Vital Signs Truth over Accuracy: • Document the true status of the patient: sick or not? • Complete vital signs on every patient, every time, regardless of the chief complaint. • If vital signs seem misleading or inaccurate, repeat them! • Beware sending a patient home with abnormal vitals (especially tachycardia)! •Treat vital signs the same as any other diagnostics— review them carefully prior to disposition. The Mother’s Vital Sign: Temperature Case #1 - 76-y/o homeless ♂ CC: 76-y/o homeless ♂ brought to the ED by police for eval.
    [Show full text]
  • Cardiovascular Assessment
    Cardiovascular Assessment A Home study Course Offered by Nurses Research Publications P.O. Box 480 Hayward CA 94543-0480 Office: 510-888-9070 Fax: 510-537-3434 No unauthorized duplication photocopying of this course is permitted Editor: Nurses Research 1 HOW TO USE THIS COURSE Thank you for choosing Nurses Research Publication home study for your continuing education. This course may be completed as rapidly as you desire. However there is a one-year maximum time limit. If you have downloaded this course from our website you will need to log back on to pay and complete your test. After you submit your test for grading you will be asked to complete a course evaluation and then your certificate of completion will appear on your screen for you to print and keep for your records. Satisfactory completion of the examination requires a passing score of at least 70%. No part of this course may be copied or circulated under copyright law. Instructions: 1. Read the course objectives. 2. Read and study the course. 3. Log back onto our website to pay and take the test. If you have already paid for the course you will be asked to login using the username and password you selected when you registered for the course. 4. When you are satisfied that the answers are correct click grade test. 5. Complete the evaluation. 6. Print your certificate of completion. If you have a procedural question or “nursing” question regarding the materials, call (510) 888-9070 for assistance. Only instructors or our director may answer a nursing question about the test.
    [Show full text]
  • (June 2000) I. INTRODUCTION WHAT IS DOCUMENTATION and WHY
    DRAFT EVALUATION & MANAGEMENT DOCUMENTATION GUIDELINES (June 2000) I. INTRODUCTION WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT? Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates: · the ability of the physician and other health care professionals to evaluate and plan the patient's immediate treatment, and to monitor his/her health care over time. · communication and continuity of care among physicians and other health care professionals involved in the patient's care; · accurate and timely claims review and payment; · appropriate utilization review and quality of care evaluations; and · collection of data that may be useful for research and education. An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary. WHAT DO PAYERS WANT AND WHY? Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate: · the site of service; · the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or · that services provided have been accurately reported. II. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION The principles of documentation listed below are applicable to all types of medical and surgical Pg. 1 services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status.
    [Show full text]
  • GUIDELINES for WRITING SOAP NOTES and HISTORY and PHYSICALS
    GUIDELINES FOR WRITING SOAP NOTES and HISTORY AND PHYSICALS by Lois E. Brenneman, M.S.N, C.S., A.N.P, F.N.P. © 2001 NPCEU Inc. all rights reserved NPCEU INC. PO Box 246 Glen Gardner, NJ 08826 908-537-9767 - FAX 908-537-6409 www.npceu.com Copyright © 2001 NPCEU Inc. All rights reserved No part of this book may be reproduced in any manner whatever, including information storage, or retrieval, in whole or in part (except for brief quotations in critical articles or reviews), without written permission of the publisher: NPCEU, Inc. PO Box 246, Glen Gardner, NJ 08826 908-527-9767, Fax 908-527-6409. Bulk Purchase Discounts. For discounts on orders of 20 copies or more, please fax the number above or write the address above. Please state if you are a non-profit organization and the number of copies you are interested in purchasing. 2 GUIDELINES FOR WRITING SOAP NOTES and HISTORY AND PHYSICALS Lois E. Brenneman, M.S.N., C.S., A.N.P., F.N.P. Written documentation for clinical management of patients within health care settings usually include one or more of the following components. - Problem Statement (Chief Complaint) - Subjective (History) - Objective (Physical Exam/Diagnostics) - Assessment (Diagnoses) - Plan (Orders) - Rationale (Clinical Decision Making) Expertise and quality in clinical write-ups is somewhat of an art-form which develops over time as the student/practitioner gains practice and professional experience. In general, students are encouraged to review patient charts, reading as many H/Ps, progress notes and consult reports, as possible. In so doing, one gains insight into a variety of writing styles and methods of conveying clinical information.
    [Show full text]
  • Chief Complaint: "Swelling of Tongue and Difficulty Breathing and Swallowing"
    Chief Complaint: "swelling of tongue and difficulty breathing and swallowing" History of Present Illness: 77 y o woman in NAD with a h/o CAD, DM2, asthma and HTN on altace for 8 years awoke from sleep around 2:30 am this morning of a sore throat and swelling of tongue. She came immediately to the ED b/c she was having difficulty swallowing and some trouble breathing due to obstruction caused by the swelling. She has never had a similar reaction ever before and she did not have any associated SOB, chest pain, itching, or nausea. She has not noticed any rashes, and has been afebrile. She says that she feels like it is swollen down in her esophagus as well. In the ED she was given 25mg benadryl IV, 125 mg solumedrol IV and pepcid 20 mg IV. This has helped the swelling some but her throat still hurts and it hurts to swallow. Nothing else was able to relieve the pain and nothing make it worse though she has not tried to drink any fluids because of trouble swallowing. She denies any recent travel, recent exposure to unusual plants or animals or other allergens. She has not started any new medications, has not used any new lotions or perfumes and has not eaten any unusual foods. Patient has not taken any of her oral medications today. Surgical History: s/p vaginal wall operation for prolapse 2006 s/p Cardiac stent in 1999 s/p hystarectomy in 1970s s/p kidney stone retrieval 1960s Medical History: +CAD w/ Left heart cath in 2005 showing 40% LAD, 50% small D2, 40% RCA and 30% large OM; 2006 TTE showing LVEF 60-65% with diastolic dysfunction, LVH, mild LA dilation +Hyperlipidemia +HTN +DM 2, last A1c 6.7 in 9/2005 +Asthma/COPD +GERD +h/o iron deficiency anemia Social History: Patient lives in _______ with daughter _____ (919) _______.
    [Show full text]
  • Emergency Department Chief Complaint and Diagnosis Data to Detect Influenza-Like Illness with an Electronic Medical Record
    UC Irvine Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health Title Emergency Department Chief Complaint and Diagnosis Data to Detect Influenza-Like Illness with an Electronic Medical Record Permalink https://escholarship.org/uc/item/9gq782tz Journal Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 11(1) ISSN 1936-900X Authors May, Larissa S Griffin, Beth Ann Bauers, Nicole Maier et al. Publication Date 2010 License https://creativecommons.org/licenses/by-nc/4.0/ 4.0 Peer reviewed eScholarship.org Powered by the California Digital Library University of California Original research Emergency Department Chief Complaint and Diagnosis Data to Detect Influenza-Like Illness with an Electronic Medical Record Larissa S. May, MD, MS* * The George Washington University, Department of Emergency Medicine, Beth Ann Griffin, PhD† Washington, D.C Nicole Maier Bauers, MS‡ † RAND Corporation, Center for Domestic and International Health Security, Arvind Jain, MS† Arlington VA Marsha Mitchum, MS, MPHҰ ‡ The George Washington University School of Public Health, Washington, D.C. Neal Sikka, MD* Ұ The George Washington University School of Medicine, Washington, D.C. Marianne Carim, MDҰ € Georgetown University School of Nursing and Health Studies Michael A. Stoto, PhD€ Supervising Section Editor: Scott E. Rudkin, MD, MBA Submission history: Submitted August 28, 2009; Revision Received July 22, 2009; Accepted July 22, 2009 Reprints available through open access at http://escholarship.org/uc/uciem_westjem Background: The purpose of syndromic surveillance is early detection of a disease outbreak. Such systems rely on the earliest data, usually chief complaint. The growing use of electronic medical records (EMR) raises the possibility that other data, such as emergency department (ED) diagnosis, may provide more specific information without significant delay, and might be more effective in detecting outbreaks if mechanisms are in place to monitor and report these data.
    [Show full text]
  • Chief Compaint/HPI History
    PULMONOLOGY ASSOCIATES OF TEXAS 6860 North Dallas Pkwy, Ste 200, Plano, TX 75024 Tel: 469-305-7171 Fax: 469-212-1548 Patient Name: Thomas Cromwell Patient DOB: 02-09-1960 Patient Sex: Male Visit Date: 03-06-2016 Chief Compaint/HPI Chief Complaint: Shortness of Breath History of Present Illness: he patient is an 56-year-old male. From the last few days, he is not feeling well. Complains of fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena. The patient relates to have some low-grade fever. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. As per the medications, they are not very clear. He denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above Pulmonary symptoms: cough, sputum, no hemoptysis, dyspnea and wheezing. History Past Medical History: Pulmonary history includes pneumonia and sleep apnea. Cardiac history includes atrial fibrillation and congestive heart failure. Remainder of PMH is non-significant. Surgical History: appendectomy in 2007. Medications: Pulmonary medications are albuterol and Spiriva; Cardiac medications include: atenolol and digoxin; Family History: Father is deceased at age 80. Father PMH remarkable for CHF, hypertension and MI; Mother is alive. Mother PMH remarkable for alzheimers, diabetes and hypertension; Cancer history in family: No Lung disease in the family: No Social History: Current every day smoker - 1 pack / day Alcohol consumption: social Marital status: lives alone Exposure History: Occupation: farmer. Asbestos exposure: None. No exposure to Ground Zero. Immunization History: Patient has an immunization history of flu shot, H1N1shot and pneumococcal shot.
    [Show full text]
  • Medical Terminology Information Sheet
    Medical Terminology Information Sheet: Medical Chart Organization: • Demographics and insurance • Flow sheets • Physician Orders Medical History Terms: • Visit notes • CC Chief Complaint of Patient • Laboratory results • HPI History of Present Illness • Radiology results • ROS Review of Systems • Consultant notes • PMHx Past Medical History • Other communications • PSHx Past Surgical History • SHx & FHx Social & Family History Types of Patient Encounter Notes: • Medications and medication allergies • History and Physical • NKDA = no known drug allergies o PE Physical Exam o Lab Laboratory Studies Physical Examination Terms: o Radiology • PE= Physical Exam y x-rays • (+) = present y CT and MRI scans • (-) = Ф = negative or absent y ultrasounds • nl = normal o Assessment- Dx (diagnosis) or • wnl = within normal limits DDx (differential diagnosis) if diagnosis is unclear o R/O = rule out (if diagnosis is Laboratory Terminology: unclear) • CBC = complete blood count o Plan- Further tests, • Chem 7 (or Chem 8, 14, 20) = consultations, treatment, chemistry panels of 7,8,14,or 20 recommendations chemistry tests • The “SOAP” Note • BMP = basic Metabolic Panel o S = Subjective (what the • CMP = complete Metabolic Panel patient tells you) • LFTs = liver function tests o O = Objective (info from PE, • ABG = arterial blood gas labs, radiology) • UA = urine analysis o A = Assessment (Dx and DDx) • HbA1C= diabetes blood test o P = Plan (treatment, further tests, etc.) • Discharge Summary o Narrative in format o Summarizes the events of a hospital stay
    [Show full text]
  • History & Physical Format
    History & Physical Format SUBJECTIVE (History) Identification name, address, tel.#, DOB, informant, referring provider CC (chief complaint) list of symptoms & duration. reason for seeking care HPI (history of present illness) - PQRST Provocative/palliative - precipitating/relieving Quality/quantity - character Region - location/radiation Severity - constant/intermittent Timing - onset/frequency/duration PMH (past medical /surgical history) general health, weight loss, hepatitis, rheumatic fever, mono, flu, arthritis, Ca, gout, asthma/COPD, pneumonia, thyroid dx, blood dyscrasias, ASCVD, HTN, UTIs, DM, seizures, operations, injuries, PUD/GERD, hospitalizations, psych hx Allergies Meds (Rx & OTC) SH (social history) birthplace, residence, education, occupation, marital status, ETOH, smoking, drugs, etc., sexual activity - MEN, WOMEN or BOTH CAGE Review Ever Feel Need to CUT DOWN Ever Felt ANNOYED by criticism of drinking Ever Had GUILTY Feelings Ever Taken Morning EYE OPENER FH (family history) age & cause of death of relatives' family diseases (CAD, CA, DM, psych) SUBJECTIVE (Review of Systems) skin, hair, nails - lesions, rashes, pruritis, changes in moles; change in distribution; lymph nodes - enlargement, pain bones , joints muscles - fractures, pain, stiffness, weakness, atrophy blood - anemia, bruising head - H/A, trauma, vertigo, syncope, seizures, memory eyes- visual loss, diplopia, trauma, inflammation glasses ears - deafness, tinnitis, discharge, pain nose - discharge, obstruction, epistaxis mouth - sores, gingival bleeding, teeth,
    [Show full text]
  • Orthostatic Vital Signs Do Not Predict 30 Day Serious Outcomes in Older Emergency Department Patients with Syncope: a Multicenter Observational Study
    YAJEM-58145; No of Pages 9 American Journal of Emergency Medicine xxx (xxxx) xxx Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study Jennifer L. White, MD a,j,⁎, Judd E. Hollander, MD a, Anna Marie Chang, MD MSCE a, Daniel K. Nishijima, MD, MAS b, Amber L. Lin, MS b, Erica Su, BS c, Robert E. Weiss, PhD c, Annick N. Yagapen, MPH, CCRP b, Susan E. Malveau, MSBE b, David H. Adler, MD, MPH d, Aveh Bastani, MD e, Christopher W. Baugh, MD, MBA f, Jeffrey M. Caterino, MD, MPH g, Carol L. Clark, MD, MBA h, Deborah B. Diercks, MD, MPH i, Bret A. Nicks, MD, MHA k, Manish N. Shah, MD, MPH l, Kirk A. Stiffler, MD m, Alan B. Storrow, MD n, Scott T. Wilber, MD m, Benjamin C. Sun, MD, MPP b a Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, United States of America b Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Heath & Science University, Portland, OR, United States of America c Department of Biostatistics, University of California, Los Angeles, CA, United States of America d Department of Emergency Medicine, University of Rochester, NY, United States of America e Department of Emergency Medicine, William Beaumont Hospital-Troy, Troy, MI, United States of America f Department of Emergency Medicine, Brigham & Women's Hospital, Boston, MA, United
    [Show full text]
  • OBCE Chart Note Guide and Templates
    Accurate Records Chiropractic Clinic 1234 Relevant Info Rd., Suite: PAR-Q PARTS, OR 97123 Ms. Vera Happy Patient: DOB 01/01/1995 Patient ID# SubLux1234 OBCE CHART NOTE TEMPLATES GUIDE Initial Visit Template: Every page must include Patient ID (name, DOB, and one unique ID number not their social security number) and Provider ID (If a page is two sided, both sides must have identifiers) (OAR 811-015- 0005(1)(a)) 1. An initial visit, no matter what the presenting complaint/conditions/or circumstance for the visit, must include: (OAR 811-015-0010(3)) a. Chief complaint for the visit (motor vehicle accident, work injury, GYN/Obstetrical, proctological, minor surgical, physiotherapy, rehab, nutritional or dietary, wellness). (OAR 811-015-0005(1)(c)(A)) i. Onset of event or events. ii. Etiology of complaint (circumstances leading up to the event) iii. Significant events that affect the presenting condition or symptom complex (what aggravates or palliates it. Its effect on daily life. Quantify the discomfort level, quality and character of the presenting complaint). (OAR 811-015- 0005(1)(c)(B)) iv. History of management of presenting complaint up to point of initial visit (other provider, urgent care, hospital, emergency room, self-treatment). (OAR 811- 015-0005(1)(c)(E)) 2. Patient’s health history (OAR 811-015-0005(1)(c)(B)) a. Illnesses b. Medications/recreational use of controlled substances c. Surgical history d. Previous injury history e. Family medical history 3. Socioeconomic history (OAR 811-015-0005(1)(c)(B)) a. Occupation/student/retired b. Hobbies/habits c. Psycho-social assessment (Example: patient alert x3) Page 1 of 4 Accurate Records Chiropractic Clinic (503) 555-1212 Dr.
    [Show full text]
  • Introduction to the Clinical Practice Guidelines
    INTRODUCTION TO THE CLINICAL PRACTICE GUIDELINES First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care. The content of this chapter was revised in December 2011. Table of Contents PURPOSE .................................................................................................................I–1 STRUCTURE ............................................................................................................I–1 Format of Body System Chapters .......................................................................I–1 Format of Medical Diagnosis/Condition Descriptions .........................................I–1 CULTURE ..................................................................................................................I–2 Commonly Cited Value ........................................................................................I–2 Culture and Health ..............................................................................................I–2 Culture and Health Care .....................................................................................I–3 TRAUMA INFORMED CARE ....................................................................................I–4 COMMUNICATION ....................................................................................................I–4 Therapeutic Relationships ..................................................................................I–4 History Taking ......................................................................................................I–4
    [Show full text]