1. U 9 Taking a Medical Hx

2. Taking a History/Interview
90% of a diagnosis can come from a good medical history/interview.

3. Culture Gender/race Language barriers White coat syndrome
Be aware of…..
Culture
Gender/race
Language barriers
White coat syndrome

4. Culture
The spouse/partner of the patient does all the talking.

5. Different medical practice…acupuncture and herbs
Culture
Spouse of patient does all the talking
Different medical practice…acupuncture and herbs

6. Gender/Race
Pt may not be comfortable with opposite sex, or from a different race/nationality.

7. Gender/Race
Pt may not be comfortable with opposite sex, or from a different race/nationality
Pt may not be comfortable with sexual orientation

8. Language Barriers
Hard to get information when you can not communicate .
ESL’s

9. White Coat Syndrome
Some people are afraid of healthcare workers, this fear changes the response to questions, test and procedures.

10. Components of a Medical Hx
Past medical hx

11. Components of a Medical Hx
Past medical hx
Family medical hx

12. Components of a Medical Hx
Past medical hx
Family medical hx
ROS-review of systems-usually done by the doctor

13. Components of a Medical Hx
Past medical hx
Family medical hx
ROS-review of systems
Current CC—chief complaint

14. What not to write in a pts chart.
She has had no rigors or shaking chills, but her husband states she was very hot in bed last night.

15. What not to write in a pts chart.
Patient was released to outpatient department without dressing. I have suggested that he loosen his pants before standing, and then, when he stands with the help of his wife, they should fall to the floor.

16. Discharge status: Alive but without permission.
What not to write in a pts chart.
Discharge status: Alive but without permission.

17. The patient refused an autopsy.
What not to write in a pts chart.
Healthy appearing decrepit 69 year-old male, mentally alert but forgetful.
The patient refused an autopsy.
The patient has no past history of suicides.

18. Past medical hx
SHIMS

19. Surgeries- any operations or procedures in the last 5 years?
Past medical hx
SHIMS
Surgeries- any operations or procedures in the last 5 years?

20. Past medical hx
SHIMS
Surgeries
Hospitalizations- have ever been in the hospital for any reason in the last 5 years

21. Injuries- any broken bones, cuts etc…
Past medical hx
SHIMS
Surgeries
Hospitalizations
Injuries- any broken bones, cuts etc…

22. Medications- are you on any medication
Past medical hx
SHIMS
Surgeries
Hospitalizations
Injuries
Medications- are you on any medication
(includes asa, or other over the counter meds, also includes…….

23. Sickness- flu, colds etc… in the last year
Past medical hx
SHIMS
Surgeries
Hospitalizations
Injuries
Medications
Sickness- flu, colds etc… in the last year

24. What not to write in a pts chart.
The patient’s past medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
The patient had waffles for breakfast and anorexia for lunch.
Between you and me, we ought to be able to get this lady pregnant.
The patient was in his usual state of good health until his airplane ran out of gas and crashed.

25. Family History
Are parents still alive?—if not, what did they die from?

26. Family History Are parents still alive?—if not what did they die from?
Any history of the following in the pts family- (family includes parents, grand parents, aunts, uncles, brothers and sisters)

27. Family History Are parents still alive?—if not what did they die from?
Any history of the following in the family
Heart disease-any form
Diabetes-type 1 or 2
Cancer-any form
Liver disease
Mental disorders

28. ROS-Review of Systems
Usually a check off sheet, filled out by the pt about their current health status.

29. What not to write in a pts chart.
Since she can't get pregnant with her husband, I thought you would like to work her up.
She is numb from her toes down.
The skin was moist and dry.

30. What not to write in a pts chart.
Coming from Detroit, this man has no children.
Patient was alert and unresponsive.
When she fainted, her eyes rolled around the room.
While in the ER, she was examined, X-rated and sent home.

31. CC-Chief Complaint
CC- Why they are seeing the doctor today. Head ache, do not feel good, pain, bleeding etc…….

32. CC Components
OPPQRST

33. CC Components
OPPQRST
O-onset of s+s

34. P-palliative- any thing that make it better
CC Components
OPPQRST
P-palliative- any thing that make it better

35. P-Provocative- any thing that makes it worse
CC Components
OPPQRST
P-Provocative- any thing that makes it worse

36. CC Components
OPPQRST
Q-Quality- if there is pain what does it feel like—i.e. stabbing, burning, pinching, dull, sharp etc….

37. CC Components
OPPQRTS
R- Radiation- does the pain or discomfort radiate/travel to other areas of the body, down the leg, up the back etc…

38. CC Components
OPPQRST
S- severity- how bad does it hurt—pain scale being very little pain, and 10 being child birth/kidney stone type of pain

39. CC Components
OPPQRST
T- timing- when does/did the cc happen? All the time , tid, qid, mornings, night etc…

40. Progress Notes
SOAPE

41. S-subjective- why they are in the office
Progress Notes
S-subjective- why they are in the office

42. O-objective-procedures, tests, exam results
Progress Notes
S-subjective- why they are in the office
O-objective-procedures, tests, exam results

43. A-assessment/dx of the problem
Progress Notes
S-subjective- why they are in the office
O-objective-procedures, tests, exam results
A-assessment/dx of the problem

44. P-plan- what is the plan for care
Progress Notes
S-subjective- why they are in the office
O-objective-procedures, tests, exam results
A-assessment/dx of the problem
P-plan- what is the plan for care

45. E- evaluation of pts understanding
Progress Notes
S-subjective- why they are in the office
O-objective-procedures, tests, exam results
A-assessment/dx of the problem
P-plan- what is the plan for care
E- evaluation of pts understanding