Patient assessment and clinical documentation

Identifying Data: Age, Gender, Occupation, and Marital Status Source and Reliability: Subjective Chief complaint or appropriate health screening visit: The one or more symptoms or concerns causing the patient to seek care. Need not be the patients complete statement may be a brief summary of reason patient wanted to be seen for this visit HPI: Complete subjective description of problem, including OLDCARTS findings or similar, including location, quality severity, duration, timing, context, modifying factors, associated signs/symptoms, relieving and aggravating factors, related systems. Medications, including OTC and Herbals Preparation Past Medical History: Allergies medications, food, environmental or seasonal Childhood Illnesses Chicken pox, Rheumatic fever, Rubella, Measles, and Mumps Adult Illnesses Injuries Surgeries Hospitalizations Obstetric/Gynecologic Psychiatric Health Maintenance Immunization status DPT, MMR, Influenza, Hepatitis, Polio, and Pneumovax Dental Exams (frequency and treatment) Last eye exam (include results) SBE/Pap/GYN (include results) Testicular/rectal exam (include results) Family History: Include presence or absence of specific illnesses in family such as hypertension, diabetes, or cancer Personal and Social History: Educational level Personal interests Lifestyle exercise and diet Older Adults ADLs and iADLs Review of Systems: Pertinent positives and negatives in the differential diagnosis Objective Vital Signs Blood Pressure Temperature Pulse Respirations Height Weight BMI including normal, overweight, obese, morbidly obese Physical Examination specific systems as appropriate Assessment and Plan (This section should process for the reader, should be based on current literature/guidelines. This should be organized and succinct.) Differential diagnoses including ICD 10 and Rationale: List the other diagnoses that should be considered in light of the history and physical findings. Rationale: Articulate a rationale for the most likely diagnosis and for each differential diagnosis. In this discussion, include pertinent positives and pertinent negatives which help to rule out or rule in each diagnosis. Most likely diagnosis: (if more than one diagnosis, number each in order of priority) Include: Pathophysiology of the problem Explanation of the diagnosis Diagnostic Testing Lab testing Radiology testing Cardiac or Neurologic testing Evaluations Physical Therapy, Occupational Therapy, Speech Therapy, or Mental Health Evaluations Medications and Treatments pharmacological and non-pharmacological treatments. Should include at least 2 evidenced based references Motivational Interviewing