DOCSLIB.ORG

Advancing Chief Complaint-Based Quality Measurement

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Advancing Chief Complaint-Based Quality Measurement Advancing Chief Complaint-Based Quality Measurement FINAL REPORT JUNE 24, 2019 This report is funded by the Department of Health and Human Services under contract HHSM-500- 2017-00060I for Task Order 75FCMC18F0005. CONTENTS EXECUTIVE SUMMARY 2 BACKGROUND 3 PURPOSE 5 METHODOLOGY AND APPROACH 6 CHIEF COMPLAINT MEASUREMENT FRAMEWORK 7 CURRENT LANDSCAPE OF CHIEF COMPLAINT STANDARDIZATION 12 ADDRESSING MEASUREMENT GAPS IN FUTURE DEVELOPMENT 16 CHIEF COMPLAINT-BASED eCQMS 19 RECOMMENDATIONS 23 NEXT STEPS 25 REFERENCES 26 APPENDIX A: Committee Members and NQF Staff 28 APPENDIX B: Definitions 30 APPENDIX C: Scan of Measures and Measure Concepts 31 APPENDIX D: Classification System Scan 32 APPENDIX E: Details of Environmental Scan Findings 33 APPENDIX F: Key Informant Interviewees 35 APPENDIX G: Sample Key Informant Interview Guide 36 2 NATIONAL QUALITY FORUM EXECUTIVE SUMMARY Emergency departments (EDs) play a central role in the delivery of acute, unscheduled care in the U.S. with nearly 145 million visits and more than one-quarter of all acute care visits.1 EDs are also the healthcare setting on the front lines of detecting disease outbreaks and linking with public health entities who monitor threats to public health. The ED’s unique role in the healthcare system enables healthcare delivery for all populations—spanning age groups, acuity, health, and socioeconomic status. Chief complaint data have historically been These approaches span the public and private collected to guide healthcare providers’ diagnostic sectors, vary in their capabilities, and are use-case- decision making and care planning in EDs and specific (e.g., syndromic surveillance, research, other settings like urgent care, primary care, and quality measurement). However, there is still no retail health settings. Chief complaints represent current guidance or consensus on how to navigate patient-reported symptoms collected at the these approaches, understand their strengths and start of a visit that describe what prompted the weaknesses, and select the best approaches and patient to seek care. Chief complaints—or other tools for a specific use case. ways of representing them such as presenting This project aimed to develop a strategic roadmap problems, clinical syndromes, or reason for visit— for advancing chief complaint data standardization are important because the chief complaint often and chief complaint-based quality measure guides diagnostic decision making and care. It is development and implementation, as well as also a vital data element collected by regional and exploring other use cases for standardized chief state public health systems to monitor for disease complaints. This project also sought to describe outbreaks. opportunities for harmonizing approaches to Chief complaint data have various uses that collecting and aggregating chief complaint data facilitate patient-centered care, decision support, across acute care and public health use cases. disease surveillance, and quality measurement. The roadmap was built on the findings of an However, the lack of standardization of chief environmental scan and key informant interviews, complaints creates challenges for use cases that which were conducted to gain an understanding require aggregation of similar patients for quality of the current landscape of chief complaint-based measures or detecting disease outbreaks. Efforts quality measurement and current approaches to resolve the challenges with standardization for standardizing chief complaint data. Based on of chief complaints have been discussed for these findings, the National Quality Forum (NQF) more than two decades. However, recent guided a multistakeholder Committee in the advancements in information technology (IT) and development of a measurement framework and informatics may present solutions to several of the recommendations to advance the implementation barriers—areas that have limited standardization. of chief complaint standardization, measure Researchers and informaticists have developed development, and implementation. several approaches and tools that can standardize chief complaints including classification systems, nomenclatures, ontologies, and IT-based tools. Advancing Chief Complaint-Based Quality Measurement 3 BACKGROUND Emergency departments (EDs) play a central role In addition to the lack of standardization upon in the delivery of acute, unscheduled care in the entry of chief complaint data, there is no accepted U.S. with nearly 145 million visits and more than standard nomenclature for classifying chief one-quarter of all acute care visits.11 EDs serve complaints for secondary uses like syndromic as a 24/7 resource for treating critical illnesses, surveillance or quality measurement. Other uses such as acute myocardial infarction, stroke, severe for chief complaint data include ED operations and trauma, and sepsis. In addition, EDs have several management (i.e., staffing, resource assessment), other functions including diagnosing acute research, and education. conditions—specifically evaluating undifferentiated Chief complaint data have historically been symptoms such as chest or abdominal pain and collected as a primary data point to guide distinguishing benign versus serious diagnoses2 healthcare providers’ diagnostic decision making that require immediate treatment. EDs often and care plan. When patients arrive in the ED, the function as a safety net for patients facing barriers chief complaint and other initial findings such as to healthcare access and when other services are the physical exam, vital signs, and other patient- not available or affordable. Nearly 60 percent of specific risk factors (e.g., medical history, age, care provided in the ED is conducted outside of gender) are often used to formulate a work-up regular business hours (8 am to 5 pm).3 EDs are plan as the clinical team seeks to determine an also a primary resource during disasters—both appropriate course of treatment and eventual natural and manmade. It is the healthcare setting diagnosis. Therefore, chief complaint data are on the front lines of detecting disease outbreaks critical in understanding whether the approaches and linking with public health entities who monitor taken are efficient and appropriate when threats to public health. The ED’s unique role in comparing across hospitals and other entities. the healthcare system enables healthcare delivery for all populations—spanning age groups, acuity, Chief complaint data have various uses that health, and socioeconomic status. facilitate patient-centered care, disease surveillance, and quality measurement. However, Chief complaints represent patient-reported the lack of standardization of these data has symptoms collected at the start of an ED visit limited its utility and makes aggregation of chief that describe what prompted the patient to seek complaints for specific use cases a complex care. Chief complaints—also commonly referred undertaking. Discussions about efforts to resolve to as presenting problems, clinical syndromes, or the challenges with standardization for quality reasons for visit—are important because the chief measurement have gone on for more than two complaint often guides diagnostic decision making decades. However, advancements in information and care. It is also a vital data element collected technology (IT) and informatics may present by regional and state public health systems to some solutions to several of the barriers that monitor for disease outbreaks. Providers typically have limited broad use of chief complaint data. record these data in a free text field in the Specifically, the high prevalence of electronic electronic health record (EHR) or paper chart, health records in EDs and other acute healthcare usually in the patient’s own words. In some cases, settings presents an opportunity to facilitate an EHR may feature a corresponding structured measurement by the adoption of systematic field in which a clinician can select one or more electronic capture of standardized chief complaint terms that align with the patient’s chief complaints. data. Standardizing chief complaints also 4 NATIONAL QUALITY FORUM presents a set of challenges with integrating new (ICD-CM), which facilitates the specification of technology or programming new capabilities into reliable quality measures. The lack of a similar existing systems, which can be expensive and approach to systematic standardization of chief complex. To address this need, researchers and complaint data has led to a persistent gap in ED informaticists have developed several approaches performance measurement. (i.e., classification systems, nomenclatures, Measuring quality in the ED using a diagnosis ontologies, and IT solutions) that span the public determined after evaluation does not address and private sectors and vary in their utility based the variability in practice required to establish on the use case (e.g., syndromic surveillance, the diagnosis from a chief complaint. Solely research, quality measurement). However, there using diagnosis limits utility when the goal is to is still no current guidance or consensus on how link similar patients to measure concepts such to navigate these approaches, understand their as resource utilization, shared decision making, strengths and weaknesses, and select the best and missed diagnoses. It is also clear that using approaches for a specific use case. final diagnosis is limited because of the poor correlation between final diagnosis and chief Quality Measurement complaint
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]