Syllabus Academic Semester(S) 2015-16 Course Title/Number Health Assessment Across the Lifespan/ NUR 245 (All Sections) Instructor: Ms
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Brain Pulsatility and Pulsatile Tinnitus: Clinical Types
EDITORIAL International Tinnitus Journal. 2012;17(1):2-3. Brain pulsatility and pulsatile tinnitus: clinical types The purpose of this commentary is to share our supported in the literature by animal and human studies evolving clinical experience with the tympanic membrane ongoing since 1980. The raw data analysis of the IPPA displacement (TMD) analyzer which has focused on wave in patients with nonpulsatile, predominantly central- brain pulsatility in nonpulsatile, predominantly central- type severe disabling SIT resistant to attempts for tinnitus type severe disabling subjective idiopathic tinnitus relief with instrumentation or medication are published (SIT) patients resistant to attempts for tinnitus relief with in this issue of the International Tinnitus Journal (see the instrumentation or medication. article “The Tympanic Membrane Displacement Test and One outcome of this evolving TMD experience Tinnitus”). has been the establishment of a classification system for In our experience, the extensive otologic, pulsatile tinnitus and its clinical translation for diagnosis neurotologic, and neuroradiolgical workup for pulsatile and treatment. tinnitus is frequently negative, and the etiology of the A new discipline, brain pulsatility, has been pulsation is a vascular hypothesis based predominantly emerging in the last 50-60 years, the principles of which on the clinical history and or physical examination. The are based on physical principles of matter, volume, and establishment of an accurate diagnosis and treatment pressure relationships in a confined area (i.e., brain) of pulsatile tinnitus has a satisfactory outcome to the and find clinical translation to the ear and the discipline patient and physician when a pathological process is of tinnitology - in particular, pulsatile tinnitus. -
Coding Tips For: PROGRESS NOTE CONTENTS
Coding tips for: PROGRESS NOTE CONTENTS PREFERRED FORMAT, PER CMS, IS THE S.O.A.P. FORMAT: SUBJECTIVE: This section should be utilized to report subjective information of clinical significance. The chief complaint of the patient belongs in this section. OBJECTIVE: This section is where you will report the measurable and observable information that you obtain during the visit. Review of systems, physical examination, any test results, outside communications with specialists should be noted in this section. ASSESSMENT: List all diagnoses and conditions assessed during the visit. Include any conditions for which prescriptions were given/renewed, tests were ordered, referrals were given. Also include any conditions in which affected decision-making for treatment. PLAN: The final section of your SOAP notes is where you outline the course of treatment, after considering the information you gathered during the visit. e text box anywhere in the document. Use the Text Box Tools tab to change the formatting of the pull quote text box.] Coding tips for: ASSURE PROGRESS NOTE COMPLIANCE The physician’s signature must be on all progress notes If the physician does not include his/her credentials as part of their signature, the full name and credentials must be printed clearly on the note The patient’s name, date of birth and DOS must be on each page of the patient’s progress note/chart Electronic Medical Records must clearly be “authenticated", “digitally signed”, “electronically signed by” the provider The medical record must be legible/complete Only standard medical abbreviations should be used Late entries can be made to clarify confirmed diagnoses. -
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 -
The AOA Guide
The AOA Guide: How to Succeed in the Third-Year Clerkships Example Notes for the MSIII 2014 Preface This guide was created as a way of assisting you as you start your clinical training. For the rest of your professional life you will write various notes, and although they eventually become second nature to you, it is often challenging at first to figure out what information is pertinent to a particular specialty/rotation.This book is designed to help you through that process. In this book you will find samples of SOAP notes for each specialty and a complete History and Physical. Each of these notes represents very typical patients you will see on the rotation. Look at the way the notes are phrased and the information they contain. We have included an abbreviations page at the end of this book so that you can refer to it for the short-forms with which you are not yet familiar. Pretty soon you will be using these abbreviations without a problem! These notes can be used as a template from which you can adjust the information to apply to your patient. It is important to remember that these notes are not all inclusive, of course, and other physicians will give suggestions that you should heed. If you are having trouble, remember there is usually a fourth year medical student on the rotation somewhere, too. We are always willing to help! Table of Contents Internal Medicine Progress Note (SOAP) ............................................................3 Neurology Progress Note (SOAP) ....................................................................... 5 Surgery ................................................................................................................. 7 Progress Note (SOAP) .................................................................................... 7 Pre-Operative Note ........................................................................................ -
EHR Go Guide: the Notes Tab
EHR Go Guide: The Notes Tab Introduction The Notes tab in the EHR contains narrative information about a patient’s current and past medical history. It is where all members of the health care team communicate about the patient during a hospital visit or while receiving outpatient care. Notes are documented on regular intervals about clinical events related to the diagnoses and treatment of the patient. There are many types of notes in the EHR including: admission notes, assessments, SOAP notes, exams, reports, screening tools, progress notes, evaluations, and more. Notes are sometimes referred to as “Flow Sheets.” Most note options are templated, meaning specific fields or questions are built in to the note for the clinician to answer, while other notes allow for free-text narrative entry. Case patients in EHR Go have existing notes in their chart. You may review these notes to gather detailed information about the patient’s condition. It is often helpful to review the patient’s notes first, to learn about the patient, before reviewing the information in the other EHR tabs. In some activities, you’ll need to write a new note. This guide explains how to access and review existing notes, edit notes, and create new notes. Additional resources Please refer to the Student Guide to EHR Go for information on logging in to Go and launching the EHR for an activity. FAQs about notes 1. Can I edit a note after I have finished it? a. Yes. In EHR Go, you may edit any existing note as often as needed. See Editing a Note section. -
Progress Notes and Psychotherapy Notes
Progress Notes and Psychotherapy Notes This Appendix covers two kinds of notes written about psychotherapy—progress notes and psychotherapy notes—and highlights the practical value of this important distinction. Progress notes are part of the client record or file, as noted below. Psychotherapy notes are not part of the file. After an overview of the client file or record, the difference between these two kinds of notes is discussed along with guides for writing progress notes. The Client File or Record The record or file of a client’s treatment at the Clinic consists of: Contact information Informed consent for treatment (including notification of rights) An intake report and/or, A written treatment plan or case formulation based on an initial assessment (i.e. interview information, formal assessment if used, and any other information collected from other sources) Progress notes documenting treatment, filed in reverse chronological order on the Clinic form Progress Note A termination note when work is concluded Other materials such as releases of information, test protocols, information obtained from other sources and so forth. The file or record does not contain psychotherapy notes (see below). Another way of saying this is that if it’s in the file, it’s not a psychotherapy note. As context for progress notes versus psychotherapy notes, please also refer to the form in Appendix D Brief Summary of Client Rights to Privacy and Access to Records and Consent to Behavioral Health Treatment and to the document in that appendix entitled Protecting the Privacy of Your Behavioral Health Information. A general intake outline is contained in Appendix C-4 Intake Outline and Report which can serve to organize information and begin treatment planning. -
Setting up a Progress Note in Ecw 11 for Medical Assistants
Setting Up a Progress Note in ECW 11 In this document, I will explain how to set up a progress note in ECW 11. When the visit is first opened, ECW asks if the medications should be carried into the note – the answer is always “Yes”. If there are any errors in the medication list from prior encounters, they will be pulled into this note as well, which is why reconciling medications is one of the most important steps in setting up a note properly. We start with the basic framework of a SOAP note. The chief complaint is pulled from the schedule - when this appointment was made, someone entered a reason, and this is pulled in as the chief complaint. The next step in most offices is to add a template to the note. At the bottom of the progress note is a panel of options. Clicking on the “Template” button opens the template screen. The current filter in the template screen is “Generic” and “All”. Once you set up your favorites, it will be much easier to quickly locate the template you wish to use by selecting “My Favorites” rather than “All” as a filter. When you find a template you like, click on “Add As Favorite” and this template will be added to your template favorites. Clicking on the magnifying glass will open a view of the template, allowing you to see what you are importing into the note. The panel at the right shows you which sections of the template will be added to the note. -
Consortium of Operative Dentistry Educators (CODE) REGIONAL
Consortium of Operative Dentistry Educators (CODE) REGIONAL REPORTS FALL 2014 Web site: http://www.unmc.edu/code 1 TABLE OF CONTENTS Foreward......................................................................................................................................... 5 Origins of CODE ........................................................................................................................... 5 Organization Operation ................................................................................................................ 7 CODE Advisory Committee ......................................................................................................... 8 Regions and Schools ..................................................................................................................... 8 2014 Agenda .................................................................................................................................10 CODE Regional Meeting Report Form ........................................................................................15 CODE Regional Attendees Form .................................................................................................17 Regional Reports: Region I (Pacific) ..........................................................................................................18 Region II (Midwest) ......................................................................................................50 Region III (South Midwest) ..........................................................................................75 -
NORTH – NANSON CLINICAL MANUAL “The Red Book”
NORTH – NANSON CLINICAL MANUAL “The Red Book” 2017 8th Edition, updated (8.1) Medical Programme Directorate University of Auckland North – Nanson Clinical Manual 8th Edition (8.1), updated 2017 This edition first published 2014 Copyright © 2017 Medical Programme Directorate, University of Auckland ISBN 978-0-473-39194-2 PDF ISBN 978-0-473-39196-6 E Book ISBN 978-0-473-39195-9 PREFACE to the 8th Edition The North-Nanson clinical manual is an institution in the Auckland medical programme. The first edition was produced in 1968 by the then Professors of Medicine and Surgery, JDK North and EM Nanson. Since then students have diligently carried the pocket-sized ‘red book’ to help guide them through the uncertainty of the transition from classroom to clinical environment. Previous editions had input from many clinical academic staff; hence it came to signify the ‘Auckland’ way, with students well-advised to follow the approach described in clinical examinations. Some senior medical staff still hold onto their ‘red book’; worn down and dog-eared, but as a reminder that all clinicians need to master the basics of clinical medicine. The last substantive revision was in 2001 under the editorship of Professor David Richmond. The current medical curriculum is increasingly integrated, with basic clinical skills learned early, then applied in medical and surgical attachments throughout Years 3 and 4. Based on student and staff feedback, we appreciated the need for a pocket sized clinical manual that did not replace other clinical skills text books available. Attention focussed on making the information accessible to medical students during their first few years of clinical experience. -
A Checklist of Key Cardio-Respiratory Interventions for Entry-Level Physical Therapy Students
A Checklist of Key Cardio-Respiratory Interventions for Entry-Level Physical Therapy Students Introduction Members of the National Association for Clinical Education in Physiotherapy (NACEP) identified the need to develop a strategy to increase clinical placement capacity in a number of geographical and practice areas. One approach which has received widespread endorsement is the development of a checklist to track key interventions for specific practice areas. Clinical research supports the assessment and treatment of the cardio-respiratory system by physiotherapists as a part of the holistic treatment of most patients. It also provides evidence for such assessments and treatments to be utilized in all practice areas, not simply those which are known to treat CR indicator conditions (e.g. heart failure, chronic obstructive pulmonary disease, diabetes). Recognizing opportunities to assess and promote the ability to perform aerobic exercise and to identify its role in chronic disease prevention will provide the student with repeated occasions to observe and participate in CR clinical experiences. All instances where a student utilizes knowledge and skills related to cardio-respiratory conditions and interventions should therefore be considered as relevant and appropriate cardio-respiratory experiences. Objectives The objectives of the CR checklist are: (1) to ensure that physiotherapy students gain experience with essential clinical skills, attitudes and behaviours within CR in order to obtain the minimum entry-level cardio-respiratory competencies prior to graduation, (2) to provide clinical supervisors with guidance as to the practice settings and clinical situations in which competence may be assessed; and (3) to highlight for students, clinical instructors and facilities that any clinical setting has the potential to assist students in acquiring CR competencies. -
Ideal Inpatient Progress Notes Template of Ideal Progress Note
Ideal Inpatient Progress Notes Template of Ideal Progress Note List of items from the survey to include in the Ideal Progress Note Subjective: • Brief narrative of events; last 24 hours Do include: 1. Summary of previous 24 hour events Objective: 2. Explain what the author is thinking • Pertinent VS 3. Document only pertinent exam findings • I&O if important to problem(s) 4. Describe the diagnosis at the appropriate level of specificity • Only pertinent labs, x-rays, imaging a. Non-specific vs. specific to support billing b. Admission dx: dyspnea; diagnosis after further Physical Exam: evaluation: CHF, systolic • Only pertinent findings 5. Only active inpatient problems 6. Pending results (labs, radiology) Assessment: 7. Keep things brief • Brief 1-2 sentence overview of current status 8. Document plan for next 24 hours • Description of patient problems that are active on this 9. Use problems (not organ systems) as structure for A&P admission 10. Justification for inpatient stay • Describe to the appropriate level of specificity o e.g. dyspnea vs. Acute on Chronic Heart Failure due Don’ts: to uncontrolled hypertension 1. Don’t copy/paste unless relentlessly editing • If you include a running summary, denote today’s changes 2. Don’t import lengthy labs, radiology, VS with bold font • Justify continued inpatient stay Plan: • Explain what the author is thinking o Differential diagnosis or clinical reasoning • Pending labs, x-rays, consults • Plan for next 24 hours (make new items bold font) Revised 4/4/12 Jeff Belden MD | [email protected] | www.toomanyclicks.com Adam Fitzgerald MD | [email protected] Family & Community Medicine | University of Missouri-Columbia EXAMPLE IDEAL PROGRESS NOTE S: Patient abdominal pain improved overnight and tolerating clear liquid diet. -
Yale Behavioral Health Services at Hamden
1 EVALUATION AND MANAGEMENT NEW PATIENT OFFICE PROGRESS NOTE Client Name:___________________________ Date of Service:_______________ Provider Name:______________________ Time In:______________am/pm Time Out:________________ am/pm Total Time Spent (minutes):_____________________ Level of Service: 99202______ 99203______99204______99205_____ COUNSELING/COORDINATION>50% of time (explain)________________________________________________________ ____________________________________________________________________________________________________ CHIEF COMPLAINT: TABULATION OF MEDICAL DECISION-MAKING ELEMENTS-Highest 2 out of 3 for Overall MDM # of Diagnoses or Points Amount and Complexity of Points Risk Factors of Presenting Number of Management Options Data Problems Management Options Self-limiting 1 Review and/or order lab data 1 One self-limited or minor Rest problem, e.g., dysthymia well- managed Minimal Risk Established problem to 1 Review and/or order radiology 1 Two or more self-limited or OTC Meds examining provider- tests minor problems; stable or improved One stable chronic illness; Low Risk Acute uncomplicated illness Established problem to 2 Review and/or order tests in 1 One or more chronic illnesses Prescription RX examining provider- the medical section of with mild exacerbation, worsening CPT progression, or side effects; Moderate Risk Two or more stable chronic illnesses; Undiagnosed new problem with uncertain prognosis; Acute illness with systemic symptoms New problem to 3 Discussion of test results with 1 One or more chronic