P ATIENT H ISTORY AND PHYSICAL EXAM (P HYSICIAN ) Chapter 16

OBJECTIVE Document the patient’s history and physical exam findings

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

P ATIENT 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

D OCUMENTING 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

A NSWERING 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

A NSWERING 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

A NSWERING 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 CHECKBOXES F IGURE 16-5 AND 16-6 Source of History: patient Onset of symptoms: immediate Progression of symptoms: increased Any previous treatment: none Frequency of pain: constant Description of pain: sharp Location of pain: lateral rest: moderate Severity w/ activity: severe Normally, physician would click described checkboxes to answer Chief Complaint and History of the Chief Complaint using Expanded Answer screen(but not in the example)

V ISIT C HART 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

P RINTING 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