Intro to H&P and Documentation
The H&P will help to establish a ___/____ relationship with your patient as well as create a
_____ diagnosis based on ____ thinking. - ANSThe H&P will help to establish a working/trusting
relationship with your patient as well as create a differential diagnosis based on clinical thinking.
The three layers of documentation include the _____, the ___, and the ____. The medical
record is a complete ___base on a ____patient. - ANSThe three layers of documentation
include the Medical Record, the history, and the physical. The medical record is a complete data
base on a single patient.
The H+P include a ____ assessment and a ____ assessment. The comprehensive assessment
is a comprehensive ____ history with a complete ____. The Focused assessment is ___ up
notes, the "____note," "____" - ANSThe H+P include a comprehensive assessment and a
focused assessment. The comprehensive assessment is a comprehensive medical history with
a complete physical. The Focused assessment is follow up notes, the "progress note," "SOAP"
The master problem list is an index that provides an ____ of the patient's ____.
-It is placed at the ____ of the medical record.
-It can be used as a ____ to ensure ____ problems are addressed.
-It can differentiate between ___symptoms and ____ symptoms of ___ disease.
-It is a reminder to do ____ care and ____up. - ANSThe master problem list is an index that
provides an outline of the patient's problems.
-It is placed at the beginning of the medical record.
-It can be used as a reference to ensure chronic problems are addressed.
-It can differentiate between new symptoms and progressive symptoms of chronic disease.
-It is a reminder to do routine care and follow up.
Flow sheets are ___ results over time.
-They look at the ____ of chronic disease.
-They are health ___ guides that can help keep track of ___ promotion and ____ prevention -
ANSFlow sheets are trend results over time.
-They look at the management of chronic disease.
-They are health promotion guides that can help keep track of health promotion and disease
prevention
Medication List includes the ___, ___, ____schedule, and ____. This list needs to be reviewed
at ___ visit to ensure ____. - ANSMedication List includes the name, strength, dosing schedule,
and compliance. This list needs to be reviewed at each visit to ensure accuracy.
What does the Medical Record include? - ANSMaster Problem List, Flow Sheets, Medication
List, Diagnostic tests and Laboratory tests
, What does SOAP stand for? - ANSSubjective, Objective, Assessment, Plan
Explain the S of Soap - ANSSubjective-What the patient tells you.
Includes: Chief complaint, History of Present Illness, Medications, Allergies, Past Medical
History, Family History, Personal and Social History, Review of Systems
Objective- data that is ___ based on the patient's ____ or your ____.
-____finding on the physical examination.
-Includes ____ findings - ANSObjective- data that is not based on the patient's report or your
opinion.
-Relevant finding on the physical examination.
-Includes lab findings
Assessment- your ____ or differential ____ based on the ____(__) and the ____ data (__).
-Can have ____ assessments based on patient's history. For example: person with HTN and
DM present with a cough. Patient smokes 1 pack per day of cigarettes. This patient has ____
different assessments and plans to deal with. - ANSAssessment- your impression or differential
diagnosis based on the history (S) and the clinical data (O).
-Can have multiple assessments based on patient's history. For example: person with HTN and
DM present with a cough. Patient smokes 1 pack per day of cigarettes. This patient has four
different assessments and plans to deal with.
Plan: what you plan to do ___ and ___ the patient. Includes the following:
-_____ plans
-____ plans
-Patient _____
-____ ___ - ANSPlan: what you plan to do for and to the patient. Includes the following:
-Diagnostic plans
-Therapeutic plans
-Patient Education
-Follow-up
Medical Record- a collection of ____ about a patient.
H+P- _____ or ____ history and ____ examination.
"____"- brief follow up note - ANSMedical Record- a collection of information about a patient.
H+P- comprehensive or directed history and physical examination.
"SOAP"- brief follow up note
What are the six tasks of the medical encounter:
1) Beginning the ____ and establishing a _____
2) _____ information for ____ and ____
3) Consulting with your ____
4) ____ and ____
The H&P will help to establish a ___/____ relationship with your patient as well as create a
_____ diagnosis based on ____ thinking. - ANSThe H&P will help to establish a working/trusting
relationship with your patient as well as create a differential diagnosis based on clinical thinking.
The three layers of documentation include the _____, the ___, and the ____. The medical
record is a complete ___base on a ____patient. - ANSThe three layers of documentation
include the Medical Record, the history, and the physical. The medical record is a complete data
base on a single patient.
The H+P include a ____ assessment and a ____ assessment. The comprehensive assessment
is a comprehensive ____ history with a complete ____. The Focused assessment is ___ up
notes, the "____note," "____" - ANSThe H+P include a comprehensive assessment and a
focused assessment. The comprehensive assessment is a comprehensive medical history with
a complete physical. The Focused assessment is follow up notes, the "progress note," "SOAP"
The master problem list is an index that provides an ____ of the patient's ____.
-It is placed at the ____ of the medical record.
-It can be used as a ____ to ensure ____ problems are addressed.
-It can differentiate between ___symptoms and ____ symptoms of ___ disease.
-It is a reminder to do ____ care and ____up. - ANSThe master problem list is an index that
provides an outline of the patient's problems.
-It is placed at the beginning of the medical record.
-It can be used as a reference to ensure chronic problems are addressed.
-It can differentiate between new symptoms and progressive symptoms of chronic disease.
-It is a reminder to do routine care and follow up.
Flow sheets are ___ results over time.
-They look at the ____ of chronic disease.
-They are health ___ guides that can help keep track of ___ promotion and ____ prevention -
ANSFlow sheets are trend results over time.
-They look at the management of chronic disease.
-They are health promotion guides that can help keep track of health promotion and disease
prevention
Medication List includes the ___, ___, ____schedule, and ____. This list needs to be reviewed
at ___ visit to ensure ____. - ANSMedication List includes the name, strength, dosing schedule,
and compliance. This list needs to be reviewed at each visit to ensure accuracy.
What does the Medical Record include? - ANSMaster Problem List, Flow Sheets, Medication
List, Diagnostic tests and Laboratory tests
, What does SOAP stand for? - ANSSubjective, Objective, Assessment, Plan
Explain the S of Soap - ANSSubjective-What the patient tells you.
Includes: Chief complaint, History of Present Illness, Medications, Allergies, Past Medical
History, Family History, Personal and Social History, Review of Systems
Objective- data that is ___ based on the patient's ____ or your ____.
-____finding on the physical examination.
-Includes ____ findings - ANSObjective- data that is not based on the patient's report or your
opinion.
-Relevant finding on the physical examination.
-Includes lab findings
Assessment- your ____ or differential ____ based on the ____(__) and the ____ data (__).
-Can have ____ assessments based on patient's history. For example: person with HTN and
DM present with a cough. Patient smokes 1 pack per day of cigarettes. This patient has ____
different assessments and plans to deal with. - ANSAssessment- your impression or differential
diagnosis based on the history (S) and the clinical data (O).
-Can have multiple assessments based on patient's history. For example: person with HTN and
DM present with a cough. Patient smokes 1 pack per day of cigarettes. This patient has four
different assessments and plans to deal with.
Plan: what you plan to do ___ and ___ the patient. Includes the following:
-_____ plans
-____ plans
-Patient _____
-____ ___ - ANSPlan: what you plan to do for and to the patient. Includes the following:
-Diagnostic plans
-Therapeutic plans
-Patient Education
-Follow-up
Medical Record- a collection of ____ about a patient.
H+P- _____ or ____ history and ____ examination.
"____"- brief follow up note - ANSMedical Record- a collection of information about a patient.
H+P- comprehensive or directed history and physical examination.
"SOAP"- brief follow up note
What are the six tasks of the medical encounter:
1) Beginning the ____ and establishing a _____
2) _____ information for ____ and ____
3) Consulting with your ____
4) ____ and ____
