PATIENT HISTORY AND PHYSICAL EXAM (PHYSICIAN)Chapter 16

OBJECTIVE

Document the patient’s history and physical exam findings

KEY CONCEPTS

History of the chief complaint Extended history Review of systems Past history Family history Social history Physical exam

PATIENT HISTORY AND PHYSICAL EXAM History and Exam section on Visit Documentation

screen Used for physician to document patient’s history and

physical exam findings Only section that does not need to be completed

prior to discharging patient All other sections are required History and exam questions based (problem-

focused) on diagnoses selected by physician If multiple diagnoses MedTrak prepares blended

checklist of history/exam questions from head to toe Questions common to each diagnosis of a multiple-

diagnoses patient visit only appear once in checklist Do This! Pg. 198

DOCUMENTING THE HISTORY AND EXAM BASED ON THE DIAGNOSIS

Place cursor in History and Exam field on Visit Documentation screen (Figure 16-1)

Click History and Exam button to display Doctor Checklist Processor screen(Figure 16-2)

Screen displays names of doctor’s checklists that correspond to diagnoses selected by physician

3 WAYS PHYSICIAN CAN ANSWER HISTORY & EXAM QUESTIONS

1. Dictation Topic: physician dictates history/exam questions

2. Detail Questions: physicians use keyboard to type answers using a detailed checklist of questions

3. Checkboxes: physicians use wireless tablet computer into exam room and check off answers on touch screen while examining patient

Do This! Pg. 200

ANSWERING QUESTIONS USING THE MACRO METHOD

Click Questions(macro) button on Doctor’s Checklist Processor screen(Figure 16-3)

Top section of buttons on left side of screen for reviewing the on-line chart and answering questions

Lower section of buttons for navigating list of questions

Do This! Pg. 201

ANSWERING QUESTIONS USING THE DETAIL METHOD

Click Questions (detail) button on Doctor’s Checklist Processor screen(Figure 16-4)

Top section of buttons on left side of screen for reviewing online chart and answering questions

Lower section of buttons for navigating list of questions

Do This! Pg. 202

ANSWERING QUESTIONS USING THE CHECKBOXES METHOD

Click Check Boxes button on Doctor’s Checklist Processor screen

MedTrak builds screen with triggers to questions appearing to right of questions with checkboxes in front of triggers for selection purposes

Answer questions by checking trigger checkboxes

Some questions answered simply by checking one or more trigger checkboxes and others may require going to Expanded Answer screen to enter more specific answers

TRIGGER CHECKBOXESFIGURE 16-5 AND 16-6

Source of History: patientOnset of symptoms: immediateProgression of symptoms: increasedAny previous treatment: noneFrequency of pain: constantDescription of pain: sharpLocation of pain: lateralSeverity @ rest: moderateSeverity w/ activity: severeNormally, physician would click described checkboxes to answer Chief Complaint and History of the Chief Complaint using Expanded Answer screen(but not in the example)

VISIT CHART

Click Submit button to record selections and stay on same screen or click Page Down button to submit changes and move down the checklist to next set of questions of following screen

Review answers using the on-line chart, click On-Line Chart button on Doctor’s Checklist screen

(Figure 16-6) On-line chart has navigation buttons to reset

specific sections of chart and plus and minus signs to use for expanding/collapsing sections of chart

After reviewing on-line chart click Exit Chart button and return to Doctor’s Checklist checkbox processor

Do This! Pg. 204-212

PRINTING THE PATIENT’S CHART

You will need to print and turn in the patient history and physical examination documentation for the patient that you completed in the electronic health record

Do This! Pg. 213