Physical findings and prior or current diagnostic test results (Objective)
General Multisystem Exam,
Diagnostic Procedures Ordered.
Assessment and identification of health risk factors, clinical impression, or diagnosis, i.e., Presenting Problems Management Options Categories. (Assessment)
Plan for care, i.e., recommendations, prescriptions for medications, diet or exercise modification, health education and counseling, and a plan of return to clinic. i.e., Management Options. (Plan)
Date and legible identity of provider.
TYPES OF HISTORY
HISTORY OF PRESENT ILLNESS (HPI) - The HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptoms or from the previous encounter to the present.
LOCATION: Are s/s are diffused or localized, unilateral or bilateral, fixed or migratory? i.e. breast tenderness, rt. ankle swollen, discharge from left ear.
QUALITY: Specific pattern of complaint, or character/quality of the s/s. Ex. sharp, dull, throbbing, constant or intermittent, acute or chronic, stable, improving or worsening, malodorous, cloudy or clear, i.e. sharp abdominal pain, foul vaginal discharge.
SEVERITY: Presence, absence and/or severity of any condition/discomfort, sensation or pain? Or does the history indicate the absence of any condition/discomfort, s/s. i.e. no c/o’s today, denies pain with exercise, c/o headache, n/v.
DURATION: Does the history indicate the duration of the s/s or problems? i.e. BTB x 3 mo., pain in left shoulder for 2 weeks.
TIMING: Does the history indicate the onset or cessation of the s/s or problems? i.e. LMP, EDC, pain started yesterday
CONTEXT: Does the history describe the patient’s locale or activity when the s/s began? When is the problem aggravated or relieved? i.e. pain with exercise, burning upon urination.
MODIFYING FACTORS: Does the history indicate what the patient has done to obtain relief? Has the patient used OTC drugs or attempted to see a MD and did it improve the condition? Exposure to STD/HIV, toxins TB, etc.? i.e. seen per MD for URI, Tylenol for headache.
ASSOCIATED S/S: Does the history list any associated s/s? such as n/v, headache, sweating, vaginal bleeding, rash, etc.?
CHRONIC/INACTIVE CONDITIONS: Does the history indicate the status of at least 3 chronic/inactive conditions? i.e. hypertension, diabetes, migraine headaches, arthritis, asthma, etc. These can be found primarily on the CH-13, CH-14.
REVIEW OF SYSTEMS (ROS)
ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms, which the patient may be experiencing or has experienced.
CONSTITUTIONAL SYMPTOMS: i.e., fever, weight change, appetite, fatigue. i.e. history of weight loss or gain, decreased or increased appetite, unexplained tiredness.
EYES: sclera, conjunctiva, pupils, etc.
CARDIOVASCULAR: lungs, heart, vascular, abdomen. i.e. SOB
RESPIRATORY: nose, mouth, lungs, heart, peripheral vascular, or skin (nails). i.e. history of asthma, TB contact.
GASTROINTESTIONAL: eyes – in relation to icterus, mouth & pharynx, lymphatic, abdomen, rectal, skin – in relation to jaundice, liver, gallbladder.
CONSTITUTIONAL: i.e. WN/WD (well nourished, well developed)
Measurement of any 3 of the following 7 vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be recorded by ancillary staff)
General appearance of patient = i.e., development, nutrition, body habitus, deformities, attention to grooming.
Inspection of conjunctiva and lids
Examination of pupils and irises (i.e. reaction to light and accommodation, size and symmetry)
Ophthalmoscopic examination of optic discs (i.e. size, C/D ratio, and appearance) and posterior segments (i.e., vessel changes, exudates, hemorrhages)
EARS, NOSE, MOUTH AND THROAT:
External inspection of ears and nose (i.e., overall appearance, scars, lesions, masses)
Otoscopic examination of external auditory canals and tympanic membranes
Assessment of hearing (i.e., whispered voice, finger rub, tuning fork)
Inspection and/or palpation of digits and nails (clubbing, cyanosis, inflammatory conditions, petechia, ischemia, infections, nodes)
Examination of joints, bones, muscles of 1 or more of the following 6 areas: 1) head and neck, 2) spine, ribs, and pelvis, 3) right upper extremity, 4) left upper extremity, 5) right lower extremity, 6) left lower extremity
The examination of a given area includes:
Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions
Assessment of range of motion with notation of any pain, crepitation or contracture
Assessment of stability with notation of any dislocation (luxation), subluxation, or laxity
Assessment of muscle strength and tone (flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements
SKIN: i.e. Skin w/d, no rashes or lesions
Inspection of skin and subcutaneous tissue (rashes, lesions, ulcers)
Palpation of skin and subcutaneous tissue (induration, subcutaneous nodules, tightening)
Test cranial nerves with notation of any deficits
Examination of deep tendon reflexes with notation of pathological reflexes (Babinski)
Examination of sensation (touch, pin, vibration)
PSYCHIATRIC: i.e. A & O x 4 (alert and oriented)
Description of patient’s judgment and insight
Brief assessment of mental status, including:
Orientation of time, place, person, and date
Recent or remote memory
Mood and affect (depression, anxiety, agitation)
DECISION MAKING - PRESENTING PROBLEMS MANAGEMENT OPTIONS CATEGORIES
Number of self limited or minor problems; i.e., cold, insect bite, tinea corporis, headache, lice, dermatitis; no apparent contraindications to immunizations/contraceptive methods.
Acute uncomplicated illness or injury, i.e., cystitis, URI, allergic rhinitis, pharyngitis, simple sprain, STD’s, OM.
Number of chronic illnesses with mild exacerbation, progression, or side effects of treatment, i.e., uncontrolled diabetes or hypertension.
Undiagnosed new problem with uncertain prognosis, i.e., lump in breast, abnormal pap smear, chest pain, developmental delay; true contraindication to immunization/contraceptive methods.
Acute condition or illness with systemic symptoms, i.e., pregnancy, pyelonephritis, pneumonitis, colitis, TB.
Acute complicated injuries, i.e., head injury with loss of consciousness
Number of chronic illnesses with severe exacerbation, progression, or side effects of treatment.
Acute or chronic condition, illness or injury that may pose a threat to life or bodily function, i.e., AIDS, high-risk pregnancy.
Abrupt change in neurological status, i.e., seizure, TIA, weakness or sensory loss.
DIAGNOSTIC PROCEDURES ORDERED - Labs performed or ordered
Drug therapy requiring intensive monitoring for toxicity
The Core Clinical Service Guide and the Administrative Reference (Volumes I and II) contain the current specific data collection and documentation requirements that comply with state and federal laws, regulations and guidelines.