Medical History and Physical Template
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Baseline Vitals &
Baseline Vitals and Sample History Company Drill Instructor Guide Session Reference: 1 Topic: Baseline Vitals and Sample History Company Drill Level of Instruction: 2 Time Required: Three Hours Materials Blood Pressure cuff & stethoscope Pen light Clock or wrist watch with second hand Writing paper Writing pencil Personal protective equipment: gloves References Brady Emergency Care, 11th Edition, The Maryland Medical Protocols for Emergency Medical Services Providers, Effective July 1, 2011, Maryland Institute for Emergency Medical Services Systems Preparation Motivation The Baseline Vitals and SAMPLE History are part of the essential information necessary to obtain and document in order to give a patient the best possible care in the field. This information can alert the provider to call for additional resources if necessary and can give those accepting care of the patient at the next level of patient care a good idea of what may be going on inside the patient’s body. Objective (SPO) 1-1: Given a live victim; blood pressure cuff; stethoscope; pencil; paper; pen light; clock or wrist watch, the student will be able to demonstrate, from memory and without assistance, the proper procedures in obtaining a set of Baseline Vitals, to include: pulse, respirations, skin color, skin temperature and condition, pupil appearance, blood pressure and be able to document the same at a practical station, as governed by The Maryland Medical Protocols for Emergency Medical Services Providers, Effective January 1, 2002 and the Brady Emergency Care, 7th Edition, EMT-Basic National Standard Curriculum. The student will also be able to score a 70% or above on a written exam. -
APPENDIX of DICTATION TEMPLATES Undergraduate Medical Education Approved By: Clerkship & Electives Commi
APPENDIX OF DICTATION TEMPLATES Undergraduate Medical Education Approved by: Clerkship & Electives Committee Date of original approval: August, 2013 Date of last review: N/A Date of next scheduled review: August, 2014 I. PURPOSE The following dictation samples are included to provide clinical clerks with guidance. II. DEFINITIONS CTU Clinical Teaching Unit MRP Most Responsible Physician PCCU Paediatric Critical Care Unit III. APPENDIX CTU - Discharge Summary Dictation Template All patients who 1) were admitted for seven or more days, and/or 2) had been admitted to the PCCU (Paediatric Critical Care Unit), and/or 3) had a complex condition or complicated course in hospital require a dictated (or typed) discharge summary. 1. Required initial information: Your name and position, most responsible physician (MRP) on the day of discharge, patient’s first and last name, PIN, who should receive this discharge summary (the MRP, the referring physician if one is known, the paediatrician or family physician of the patient (if not the referring physician), and other consultants who are going to see the patient in follow-up. Example: “This is John Smith, clinical clerk for Dr. X, dictating on patient Getme Outofhere, PIN 00000000. Please forward copies to Dr. X, Victoria Hospital, Dr. Y, family physician in London, Dr. Z, Paediatrician in London.” 2. Most responsible diagnosis: Diagnosis primarily responsible for the patient’s current admission. 3. History of present illness: Essential history of chief complaint as given by patient and/or care providers. It should include a concise summary of the relevant information from the time the symptoms started and up to the arrival at the Emergency Department. -
ABCDE Approach
The ABCDE and SAMPLE History Approach Basic Emergency Care Course Objectives • List the hazards that must be considered when approaching an ill or injured person • List the elements to approaching an ill or injured person safely • List the components of the systematic ABCDE approach to emergency patients • Assess an airway • Explain when to use airway devices • Explain when advanced airway management is needed • Assess breathing • Explain when to assist breathing • Assess fluid status (circulation) • Provide appropriate fluid resuscitation • Describe the critical ABCDE actions • List the elements of a SAMPLE history • Perform a relevant SAMPLE history. Essential skills • Assessing ABCDE • Needle-decompression for tension • Cervical spine immobilization pneumothorax • • Full spine immobilization Three-sided dressing for chest wound • • Head-tilt and chin-life/jaw thrust Intravenous (IV) line placement • • Airway suctioning IV fluid resuscitation • • Management of choking Direct pressure/ deep wound packing for haemorrhage control • Recovery position • Tourniquet for haemorrhage control • Nasopharyngeal (NPA) and oropharyngeal • airway (OPA) placement Pelvic binding • • Bag-valve-mask ventilation Wound management • • Skin pinch test Fracture immobilization • • AVPU (alert, voice, pain, unresponsive) Snake bite management assessment • Glucose administration Why the ABCDE approach? • Approach every patient in a systematic way • Recognize life-threatening conditions early • DO most critical interventions first - fix problems before moving on -
Clinical Handbook Health Care for Children Subjected to Violence Or Sexual Abuse
KINGDOM OF CAMBODIA NATION RELIGION KING MINISTRY OF HEALTH CLINICAL HANDBOOK HEALTH CARE FOR CHILDREN SUBJECTED TO VIOLENCE OR SEXUAL ABUSE 2017 PREFACE Violence against children is a serious public health concern and a human rights violation with consequences that impact their lives in various ways. Violence and sexual abuse suffered in childhood adversely affects the body as well as the mind, which can lead to a broad range of behavioral, psychological and physical problems that persist into adulthood. Healthcare practitioners play a significantly important role in prevention and response to violence against children. They are often the first or only point of reference for children who have experienced violence, detecting abuse and providing immediate and longer-term care and support to children and families. In 2015, the Ministry of Health developed “the National Guidelines for Management of Violence Against Women and Children in the Health Sector”, which provides health care centers and referral hospitals with an overview of prevention and response in the health sector to violence against women and children. This “Clinical Handbook on Health Care for Children Subjected to Violence or Sexual Abuse” elaborates on knowledge and skills required to implement the National Guidelines. It aims to serve as a guide to ensure a prompt and adequate response to child victims of violence or sexual abuse for all healthcare practitioners. It provides further guidance on first line support, medical treatment, psychosocial support, and referral to key social and legal protection services. It can be also used as a resource manual for capacity development and training. Phnom Penh, 30th January 2017 Prof. -
Adm Notepreophp
Patient Name: Admission Note: Part 1 Date of Birth: History and Physical Examination Admission Date: Ophthalmology - Pediatric Admitting Physician (FULL NAME W/MIDDLE INITIAL): Preferred English Chinese Mandarin Cantonese Language Spanish Russian Other: Chief Complaint/History of Present Illness: (admit note must contain justification for surgery) Visual impairment resulting in limitation of activities of daily living Diplopia Asthenopia Glare/Light sensitivity Uncontrolled intraocular pressure Severe eye pain Retinal detachment Eyes not aligned Impaired binocular vision Abnormal head position Impaired visual development Please specify other indications/justifications: Clinical History or Conditions Present On Admission: No pertinent clinical history Diabetes (please specify): Insulin Dependent Oral Medication Diet Controlled Cardiac: Congenital Heart Defect Other : Neuro: Mental/developmental delay Seizures/seizure disorder Other: Pulmonary: Asthma Other : Other Hx: Hx of Multidrug-Resistant Organism (MDRO) within past 12 months Isolation status if required: Contact Other Allergies: No Known Allergies Latex If Allergies, list: Ophthalmic Exam Right Eye Left Eye Visual Acuity Motility Lids/Adnexa Intraocular Pressure Anterior Segment Posterior Segment Other: Please refer to Pediatric Medical Evaluation for review of systems and physical examination of pertinent organ systems other X than those related to admission diagnosis ASSESMENT/PLAN Admission Diagnosis: ICD-10 Code: Planned Procedure(s) with CPT codes: FemtoSecond ORA OTHER: Laterality: Right Left Bilateral N/A Anesthesia: General MAC/Sedation Local Other: Continue to page 2 for Orders Revised 10.22.2020 *ADM NOTEPREOPHP* ADM NOTEPREOPHP ADM.075 Patient Name: Admission Note: Part 2 History and Physical Examination Date of Birth: Admission Date: Ophthalmology - Pediatric Admitting Physician (FULL NAME W/MIDDLE INITIAL): Preferred English Chinese Mandarin Cantonese Language Spanish Russian Other: 1. -
Vital Signs and SAMPLE History
CHAPTER 9 Vital Signs and SAMPLE History Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Overall Assessment Scheme Scene SizeSize--UpUp Initial Assessment Trauma Medical Physical Exam SAMPLE History Vital Signs & Physical Exam SAMPLE History & Vital Signs HOSP Detailed Ongoing Physical Exam Assessment Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Baseline Vital Signs Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Baseline Vital Signs Pulse Respirations Skin Pupils Blood Pressure Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Pulse Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Pulse Rate Adults generally 60-100/minute. Tachycardia is pulse more than 100/minute. Bradycardia is pulse less than 60/minute. More than 120 or less than 50 may be a critical finding. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Pulse Quality Strong or weak Regular or irregular Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ If you cannot feel a radial or brachial pulse, check the carotid pulse. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Respirations Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Respiratory Quality Normal Shallow Labored Noisy Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. -
Sample History and Physical Note for Gout
Sample History and Physical Note Charting Plus™ - Electronic Medical Records www.medinotes.com Note for Jane Doe on 2/27/04 - Chart 5407 Chief Complaint: This 31 year old female presents today with abdominal pain. Duration: Condition has existed for one month. Modifying Factors: Patient indicates lying down improves condition and standing worsens condition. Severity: The severity has worsened over the past 3 months. LMP: 4-05-2002. Allergies: Patient admits allergies to penicillin. Medication History: None. Past Medical History: Past medical history is unremarkable. Past Surgical History: Patient admits past surgical history of (+) cholecystectomy in 1998. Social History: Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use. Family History: Patient admits a family history of cancer of breast associated with mother. Review of Systems: Cardiovascular: (-) cardiovascular problems or chest symptoms Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness Genitourinary: (-) GU symptoms Physical Exam: BP Standing: 118/72 Resp: 18 HR: 68 Height: 5 ft. 7 in. Weight: 134 lbs. Patient is a 31 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus. Eyes: Conjunctiva and lids reveal no signs or symptoms of infection. Pupil exam reveals round and reactive pupils without afferent pupillary defect. Optic discs with normal color, contour and cupping bilaterally. Retinas are flat with normal vasculature out to the far periphery with no peripheral holes, breaks or tears observed. ENT: Gross hearing test reveals normal hearing. Inspection of bilateral ears reveals no masses, swelling, redness or drainage. -
General Rules of the Marquette General Health System Medical Staff
General Rules of the Marquette General Health System Medical Staff I. PATIENT ADMISSION, ALTERNATE COVERAGE, TRANSFER, DISCHARGE AND DEATH 1.1 ADMISSION CRITERIA 1.1-1 Who may admit patients. Only a Member with admitting privileges may admit or co-admit a patient to the Hospital. Except as provided for Qualified Oral Surgeons, Podiatrists and Independent Allied Health Professionals in the Medical Staff Bylaws, a physician Member will be responsible for the general medical care and treatment of every patient admitted to the Hospital. Medical care may be provided by a Resident, other specified professional personnel or Allied Health Staff members provided they are working under the supervision of a Practitioner with clinical privileges. Medical care will be provided only by Members and Hospital support staff authorized to perform such services. 1.1-2 Admission Information. An admitting Practitioner will provide the following information in the patient’s medical record, if such information is available to the admitting Practitioner: (a) Provisional diagnosis. (b) A valid reason for admitting the patient, including information to support the medical necessity and the appropriateness of the admission. (c) Information needed to properly care for the patient being admitted. (d) Information needed to protect the patient from himself/herself. (e) Information needed to protect Hospital personnel and others from potential problems or dangers presented by the patient. (f) Information deemed necessary by the Hospital. 1.1-3 Admission of potentially suicidal or dangerous patients. If an admitting Practitioner reasonably believes a patient admitted for other purposes is potentially suicidal or dangerous to himself/herself or others, the admitting Practitioner will promptly obtain a consultation from a suitable mental health professional. -
Resident Supervision Attending Practitioner Responsibilities for Physician, Dental, Optometry, & Podiatry Residents
U.S. DEPARTMENT OF VETERANS AFFAIRS Resident Supervision Attending Practitioner Responsibilities for Physician, Dental, Optometry, & Podiatry Residents “Supervising Practitioner” (synonymous with “Attending”): Responsible for all care in which interns, residents or fellows are involved. “Resident” is used to apply to physician, dentist, optometrist, and podiatrist residents and fellows, regardless of training level. Documentation of all patient encounters must identify the supervising practitioner (attending) by name and indicate the level of involvement. Depending upon the clinical situation, Four types of documentation of resident supervision are allowed: 1. Attending’s progress note or other entry into the patient health record. 2. Attending’s addendum to the resident admission or progress note. 3. Co-signature by the attending implies that the attending has reviewed the resident note or other health record entry, and absent an addendum to the contrary, concurs with the content of the resident note or entry. Use of CPRS function "Additional Signer" is not acceptable for documenting supervision. 4. Resident documentation of attending supervision. [Includes involvement of the attending and the attending’s level of supervision or oversight responsibility (e.g., "I have seen and discussed the patient with my attending, Dr. 'X', and Dr. 'X' agrees with my assessment and plan"), at a minimum, the responsible attending should be identified (e.g., "The attending of record for this patient encounter is Dr. 'X'")] Outpatient: New Patient Visit (includes Emergency Department visits) Attending must be physically present in the clinic. Every patient who is new to the facility must be seen by or discussed with an attending. Documentation: An independent note, addendum to the resident's note, or resident note description of attending involvement. -
Student Clerkship Guide a Comprehensive Guide to Clerkship at the Ottawa Hospital
STUDENT CLERKSHIP GUIDE A COMPREHENSIVE GUIDE TO CLERKSHIP AT THE OTTAWA HOSPITAL Gemma Cox and Stephanie Lubchansky MD 2015 CANDIDATES SPECIAL THANKS To Dr. Krista Wooller for her guidance, support, and feedback during the writing process. The Faculty of Medicine at the University of Ottawa for supporting this endeavor. EDITORS-IN-CHIEF EDITORS Gemma Cox, MD Candidate 2015 Pierre-Olivier Auclair, Mandatory Selectives Coordinator Stephanie Lubchansky, MD Candidate 2015 Dr. Contreras-Dominguez, Internal Medicine Rotation Director FACULTY SUPERVISOR Kelly Frydrych, MD Candidate 2015 Dr. Krista Wooller Julie Ghatalia, Department of Anesthesiology CONTRIBUTORS Celine Giordano, MD Candidate 2015 Kevin Dong, MD Candidate 2015 Hilary Gore, Department of Obstetrics and Bani Falcon, MD Candidate 2015 Gynecology Kelly Frydrych, MD Candidate 2015 Dr. Laura Hopkins, Obstetrics and Habibat Garuba, PGY-2 Internal Medicine Gynecology Rotation Director Celine Giordano, MD Candidate 2015 Dr. B.K. Lam, Surgery Rotation Director Anne McHale, MD Candidate 2015 Dr. Tim Lau, Department of Psychiatry Department of Pediatrics, Children’s Dr. Safeena Kherani, Mandatory Selectives Hospital of Eastern Ontario (CHEO) Rotation Director Department of Surgery, The Ottawa Anne McHale, MD Candidate 2015 Hospital Dr. Eoghan O’Shea, Family Medicine Rotation Diector Dr. Nikhil Rastogi, Anesthesiology Rotation Director Brigitte Rutherford, Department of Psychiatry Denis Vadeboncoeur, 3rd year Liaison Officer Dr. Krista Wooller, Department of Internal Medicine Amy Whyte, Department of Surgery Donna Williams, Department of Family Medicine Dr. Stella Yiu, Emergency Medicine Rotation Director Dr. Marc Zucker, Pediatrics Rotation Director A FEW WORDS FROM THE EDITORS IN CHIEF… This guide was created to help orient you, the incoming clerkship class, to the many experiences that you will encounter over the course of this year. -
Emergency Care
Emergency Care THIRTEENTH EDITION CHAPTER 14 The Secondary Assessment Emergency Care, 13e Copyright © 2016, 2012, 2009 by Pearson Education, Inc. Daniel Limmer | Michael F. O'Keefe All Rights Reserved Multimedia Directory Slide 58 Physical Examination Techniques Video Slide 101 Trauma Patient Assessment Video Slide 148 Decision-Making Information Video Slide 152 Leadership Video Slide 153 Delegating Authority Video Emergency Care, 13e Copyright © 2016, 2012, 2009 by Pearson Education, Inc. Daniel Limmer | Michael F. O'Keefe All Rights Reserved Topics • The Secondary Assessment • Body System Examinations • Secondary Assessment of the Medical Patient • Secondary Assessment of the Trauma Patient • Detailed Physical Exam continued on next slide Emergency Care, 13e Copyright © 2016, 2012, 2009 by Pearson Education, Inc. Daniel Limmer | Michael F. O'Keefe All Rights Reserved Topics • Reassessment • Critical Thinking and Decision Making Emergency Care, 13e Copyright © 2016, 2012, 2009 by Pearson Education, Inc. Daniel Limmer | Michael F. O'Keefe All Rights Reserved The Secondary Assessment Emergency Care, 13e Copyright © 2016, 2012, 2009 by Pearson Education, Inc. Daniel Limmer | Michael F. O'Keefe All Rights Reserved Components of the Secondary Assessment • Physical examination • Patient history . History of the present illness (HPI) . Past medical history (PMH) • Vital signs continued on next slide Emergency Care, 13e Copyright © 2016, 2012, 2009 by Pearson Education, Inc. Daniel Limmer | Michael F. O'Keefe All Rights Reserved Components of the Secondary Assessment • Sign . Something you can see • Symptom . Something the patient tell you • Reassessment is a continual process. Emergency Care, 13e Copyright © 2016, 2012, 2009 by Pearson Education, Inc. Daniel Limmer | Michael F. O'Keefe All Rights Reserved Techniques of Assessment • History-taking techniques . -
Junior Doctor Skill in the Art of Physical Examination: a Retrospective Study of the Medical Admission Note Over Four Decades
Open Access Research BMJ Open: first published as 10.1136/bmjopen-2012-002257 on 3 April 2013. Downloaded from Junior doctor skill in the art of physical examination: a retrospective study of the medical admission note over four decades Charlotte M Oliver,1 Selena A Hunter,2 Takayoshi Ikeda,3 Duncan C Galletly2 To cite: Oliver CM, ABSTRACT et al ARTICLE SUMMARY Hunter SA, Ikeda T, . Objectives: To investigate the hypothesis that junior Junior doctor skill in the art doctors’ examination skills are deteriorating by assessing of physical examination: a Article focus the medical admission note examination record. retrospective study ▪ There is well-documented international evidence of the medical admission Design: Retrospective study of the admission record. supporting a declining standard in junior note over four decades. BMJ Setting: Tertiary care hospital. doctors’ physical examination skills in recent Open 2013;3:e002257. Methods: The admission records of 266 patients years. doi:10.1136/bmjopen-2012- admitted to Wellington hospital between 1975 and 2011 ▪ This study was conducted to address the 002257 were analysed, according to the total number of physical research question that this deterioration has examination observations (PEOtot), examination of the occurred locally in Wellington, New Zealand. ▸ Prepublication history for relevant system pertaining to the presenting complaint this paper are available (RelSystem) and the number of body systems examined Key messages ▪ There has been a decline in the quantity and online. To view these files (Nsystems). Subgroup analysis proceeded according to quality of the medical admission note examin- please visit the journal online admission year, level of experience of the admitting (http://dx.doi.org/10.1136/ ation records in this tertiary care centre between doctor (registrar, house surgeon (HS) and trainee intern bmjopen-2012-002257).