EHR notes week 2

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School

University of Phoenix *

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Course

HCS/235

Subject

Medicine

Date

Dec 6, 2023

Type

docx

Pages

3

Uploaded by MinisterIronJay1603

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Features of an electronic health record (EHR) include: Patient portals Electronic medical records (EMRs) from each practice E-prescribing Medical history Information sharing (interoperability) Integration with other applications Payment management Customized templates Communication (anywhere with an internet connection) Charting and reporting S – Subjective - This is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them. In the inpatient setting, interim information is included here. Chief Complaint (CC) – The CC, or presenting problem, can be a symptom, condition, previous diagnosis, or another short statement that describes the CC History of Present Illness (HPI) – Begins with a simple one line statement including the patient’s age, sex, and reason for the visit. Ex: 47 year old female presenting with abdominal pain. Use OLDCARTS Onset: When did the CC begin? Location: Where is the CC located? Duration: How long has the CC been going on for? Characterization: How does the patient describe the CC? Alleviating and Aggravating factors: What makes the CC better? Worse? Radiation: Does the CC move or stay in one location? Temporal factor: Is the CC worse (or better) at a certain time of the day? Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC? History Medical history: Pertinent current or past medical conditions Surgical history: Try to include the year of the surgery and surgeon if possible. Family history: Include pertinent family history. Avoid documenting the medical history of every person in the patient's family.
Social History: An acronym that may be used here is HEADSS which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression. Review of Systems (ROS) - This is a system based list of questions that help uncover symptoms not otherwise mentioned by the patient. General: Weight loss, decreased appetite Gastrointestinal: Abdominal pain, hematochezia Musculoskeletal: Toe pain, decreased right shoulder range of motion Current Medications, Allergies - Current medications and allergies may be listed under the Subjective or Objective sections. However, it is important that with any medication documented, to include the medication name, dose, route, and how often. Example: Motrin 600 mg orally every 4 to 6 hours for 5 days Objective - This section documents the objective data from the patient encounter. This includes: Vital signs Physical exam findings Laboratory data Imaging results Other diagnostic data Recognition and review of the documentation of other clinicians **Be aware when distinguishing between symptoms and signs. Symptoms are the patient’s subjective description and should be documented under the subjective heading, while a sign is an objective finding related to the associated symptom reported by the patient. An example of this is a patient stating he has “stomach pain” which is a symptom, documented under the subjective heading, versus “abdominal tenderness to palpitation” an objective sign documented under the objective heading.** Assessment - This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems. Elements include the following. Problem – List the problems in order of importance. A problem is often known as a diagnosis. Differential Diagnosis - This is a list of the different possible diagnosis, from most to least likely, and the thought process behind this list. This is where the decision-making process is explained in depth. Included should be the possibility of other diagnoses that may harm the patient, but are less likely.
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