Onset – “When did it start? What were you doing when it started?”
Provoking/Palliating – “What makes the pain better and/or worse? Ex. Medications?”
Quality of pain – “Describe the pain – is it dull, sharp, achy, constant, intermittent?”
Radiate – “Does your pain radiate anywhere?”
Symptoms – “Are there any other symptoms associated with your CC?”
Time Course – “When did it start? Is it improving/worsening/staying the same? Was there a trigger? What do you think is causing your pain?”
Focused ROS: Always ask general ROS such as F/C/NS/Wt Loss/CP/SOB/N/V/D then stick to regional anatomy involved, unless general complaint such as fever – then ask ROS for entire body. (Ex. Headache: ROS about vision, hearing, balance, taste, thirst). NOTE: ROS CAN BE YOUR MOST HELPFUL TOOL AT ARRIVING AT THE CORRECT DIAGNOSIS!!
PMHx: (include hospital admissions)
MEDS: (ask your pt every time, and document separate from AHLTA auto-entry, as auto-entry is often wrong)
ALL: (ask your pt every time, and document separate from AHLTA auto-entry, as auto-entry is often wrong)
PE: (Head to toe: at a minimum do HEENT w/ CNII-XII, CV, PULM, ABD to improve your PE skills; do not write ‘normal’ or ‘unremarkable’ because I don’t know what you tested)
GEN: (do they appear clinically ill?)
+/- MSK: Inspection, Palpation, ROM, Strength, Reflexes, Neuro (Light touch), Vascular (Pulses/Cap Refill), Special Tests – always perform MSK on both sides and document (‘symmetric ROM’ or ‘asymmetric ROM’)
Problem List:List all items that are abnormal in history and PE (include vitals). Your DDx should then be generated from this problem list.
Assessment: __y/o M/F presents with CC of ____ and associated symptoms (what the pt told you) of ___________ x ___days and associated signs (what you found in vitals and PE) supporting the diagnosis of _____.
Differential Diagnosis: (include at least 3, make sure each diagnosis has at least 1 supporting factor from the history in your note. Ex. ‘Migraine HA: supported by sensitivity to light and throbbing nature of HA’; also say why you think each dx is more or less likely).
PLAN: Your plan should be generated from your problem list and Dx. Each main problem discovered above should have a separate plan (ex. CC, smoking, obesity).
Diagnostic Plan: list imaging, labs, referrals to specialty clinics.
If you order labs and/or imaging, you must inform pt of results and document that you did. Its ok to addend this note, or write new note recording results and that you informed your pt of those results.
Therapeutic Plan: list medications, physical therapy, light duty chits.
F/U Plan: needed for every patient. Can write “F/U as needed” BUT most pt’s should have a f/u scheduled. If you write F/U in ___ days, you must have new note or addend this note with brief f/u information (How is patient doing? Have sx’s resolved?)
Prev Med and Other items in problem list that need to be addressed: