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Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care. Jim is a 69-year-old male who comes in today complaining of dyspnea on exertion, and you have noted that he has gained about 25 pounds since his last visit 7 months ago. He tells you that he is not sleeping at night because of a constant cough, and he thinks he has a cold because he is coughing up pink frothy “spit”. He is extremely fatigued because of his lack of sleep. Your examination reveals bilateral 3+ pitting edema with his lower extremities being cool to the touch, distended abdomen, hepatomegaly, hacking cough, and S3 with a gallop. Jim had a myocardial infarction (MI) 15 years ago, and his currently on medication for hypertension. Must be in SOAP note format Ex: Tips for SOAP/H&P notes ? The H&P is of course more thorough and a SOAP note is more focused depending on cc. ? If it’s not documented, it’s NOT done. ? Poor documentation can cost you a lot in the long run. It may feel like you don’t have time to document it all but learn your EHR and shortcuts that can help you become more efficient. ? Documentation is a reflection of your care of patients i.e. errors, lazy, sloppy, distracted. ? Remember to connect information in HPI to the diagnosis in plan with intervention. Give yourself credit for the education you are doing. This is important if ever reviewed and for billing. A few dollars missed for “x” amount of patients per day can soon add up. You want to show your worth in a practice. You are an income producing employee as an NP. o Problem statement (chief complaint) o Subjective (history) o Objective (physical exam/diagnostics) o Assessment (diagnosis) o Plan (orders) o Rationale (clinical decision making) Remember the ROS is what the patient complains of and the physical exam is a documentation of your findings. These are often mixed up by new providers, when documenting. S – Subjective.? What the patient or “subject” tells you. You can use quotes, such as “I have been to 20 doctors”. This can also be obtained from caregivers such as parents/grandparents or children. This will guide PE and assessment/plan. Reports of compliance with specific treatment regimens should also be included here: i.e. “How much of your medication did you take since your last visit? Did you miss any doses? Why?” or “At the last visit, you were given antibiotics for pneumonia. Do you have any pills left?” Example: This _____ yr. old, fe/male with a past medical hx of ____, presents with/for _______. o Components: ? Chief complaint? (it’s like the title of the paper) ? History of present illness? – remember location, quality, severity, duration, timing – onset and frequency, context, relieved by, worsened by, associated signs and symptoms. ? Past medical history? – ? Chronic medical problems? – list if they have had surgical interventions or if undergoing treatment such as chemo for cancer, and list the treatment. Antibiotics – list how many days on, particularly if long term antibiotics. ? Surgical history? – include year and surgeon if you have that information ? Social history? – alcohol, illicit drugs and nicotine – current or past. Would also ask about caffeine & smokeless tobacco. Seatbelt use. Fire alarms. Marital status, children, #in household, occupation, nutrition, exercise, sexual activity, contraception, education. ? Family history? – if you will list per family member – mother, father, siblings and children, it will help you in the future. ? Hospitalizations ? Immunizations –? follow evidence based practice for age ? Preventative care? – follow evidence based practice for age, chronic illness and/or medications that patient is on. ? Reproductive history? – always check current status/pregnancy test before starting new meds! ? Childhood/adult illnesses ? Allergies? – list reaction (some people say they are allergic to PCN because mom was) O – ? ?Objective ? Medications? – follow evidence based practice for chronic illness and age (i.e. Diabetes, heart disease, etc.). Include OTC/herbs. ? ROS? – you may put pertinent positives and negatives here, then in your separate ROS say “all ___systems reviewed and are negative except for what is listed in HPI” You can only put this statement if you have listed ROS in the HPI. Otherwise you must list pertinent ROS. If it is a H&P, you must list all ROS. ? Vital signs ? Physical Exam:? figure out a good template that encompasses the picture of the patient. This helps the next provider following you. Try to stay away from “normal”. Occasionally it fits because there is a normal but often your normal is not my normal. T? his is one of many, many examples: o General (a good picture of the patient?): Ms. _____ is a 49-yo, Caucasian female who is alert and oriented x 3 and who appears younger than stated age. Patient is well developed, well-nourished, in no acute distress. Patient is well groomed and dressed appropriately for the season. o Eye:? Pupils are equal, round and reactive to light, Extraocular movements are intact, Conjunctiva is clear. Sclera is non-icteric. No exudates or hemorrhages. o HENT:? Atraumatic. Normocephalic, no visible or palpable masses, depressions or scaring. Hearing intact. Ear canals clear and patent. TMs translucent and mobile. Oral mucosa is moist, No pharyngeal erythema or exudates, no mucosal lesions. o Neck:? Supple, Non-tender, No jugular venous distention, No lymphadenopathy, No thyromegaly. No bruits. o Respiratory:? Lungs are clear to auscultation bilaterally, no wheezing or rhonchi noted. Respirations are non-labored, Breath sounds are equal, Symmetrical chest wall expansion. o Cardiovascular:? Regular rate and rhythm, No murmur, No gallop, Good pulses equal in all extremities, Adequate peripheral perfusion with capillary refill <3 seconds, No edema. o Gastrointestinal:? Soft, Non-tender, Non-distended, Positive bowel sounds in all quadrants, No organomegaly. No hepatosplenomegaly. No hernias or palpable masses. o Genitourinary:? No costovertebral angle tenderness. (Can add specifics per male or female) o Lymphatics: N? o lymphadenopathy neck, axilla, groin. o Musculoskeletal:? No abnormalities of gait or station. No misalignment, decreased range of motion, instability, asymmetry, crepitus, defects, swelling, tenderness or masses. No atrophy, abnormal strength or tone. o Integumentary:? Good turgor. No rashes, unusual bruising or prominent lesions. Warm, Dry, Pink, and Intact. o Neurologic:? No focal deficits, Cranial Nerves II-XII are grossly intact. Sensation intact. No pathologic reflexes. DTRs 2+ in upper and lower extremities. o Psychiatric:? Alert, Oriented x 3. Cooperative, Appropriate mood & affect. Intact recent and remote memory, judgement and insight. ? Labs/diagnostic studies? – document these were personally reviewed by you and the results A/P – ?You can separate these or put together – it is a personal preference. I list mine together as it helps with my flow. This is where you will pull it all together from cc to physical exam with labs/diagnostics and list all diagnosis that you talked about with the plan/interventions. Give yourself credit! ? Most acute diagnosis (not symptoms) first ? Don’t forget obesity and smoking cessation ? New medications – educate on side effects and to call the office sooner than scheduled appt if s/s worsen ? Add in if you check controlled substance registry for controlled substances. When last meds were filled, pill counts in the office, urine drug screens, educations, narcan and keeping prescriptions to one provider and one pharmacy. ? Advanced directives Example: 1. Lumbago (not low back pain)? – this is new for the patient. No known injury. L-spine x-ray reveals _______________. Will attempt conservative measures with weight loss, exercise, heat, and NSAIDs. Patient is to return to the office in _____ days. Educated on side effects of NSAIDs _______________. The patient was given specific exercises to perform ___________ times per day and verbalizes understanding of these instructions and agrees to this plan. The patient verbalized an understanding to call the office for a sooner appointment, if symptoms worsen. If the patient reports that the aforementioned measures have failed to provide symptom relief at the follow up visit, consider outpatient physical therapy and further diagnostic studies, such as MRI. Rx for Mobic 7.5 mg PO BID x 7 days sent electronically to the patients’ pharmacy CVS - _________ #14 with no refills. Note:? Make sure you document if patient agrees or refuses your recommendation. This can make a huge difference if you were to be sued. Differential diagnosis:? _____________________. Would encourage you to think about the zebra diagnosis. Practice, practice, practice!

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