Professionalism in Health Care & Overview of P.E. Course
Subjective:
DESCRIPTORS
1 .Mode of Onset of a symptom
Describe Events coinciding with the onset
Onset Gradual or sudden
Total Duration of the Symptoms
2. Location of the symptom (be precise)
3. Character of the symptom (dull, sharp, etc.)
4. Radiation of the symptom
5. Frequency of the symptom
6. Precipitating factors (caused?)
7. Aggravating factors (made worse?)
8. Relieving or amelioration factors (make better?)
9. Associated symptoms (anything with symptoms)
10. Course of symptoms (getting worse or better)
11. Effect of symptom on daily life
12. Past treatment or evaluation of the symptom
When, Where, by Whom
What studies were done and what were the results
Results of past treatment
Past diagnosis
13. Patients Concerns
Chief Complaint needs to be there (from the Patient) – need to examine that Complaint (and any other you find).
Social History – Married, Work, Insurance
Habit – Diet, Drugs, Exercise
Objective:
List the Physical finding RELEVANT to the complaints
Complete History & Physical – All Systems
Episodic History & Physical – only the systems pertinent to the Chief Complaint
Review of Systems (ROS):
RECORD ALL NEGATIVES
Assessments:
Acute Diagnoses
Strept Throat or Pneumonia
Symptoms or Signs not yet diagnosed
Cough or Urinary frequency
Past Problems
Abnormal Pap 1 year ago or s/p tonsillectomy or History of drug allergy
Health Risk Factors
Smoking or Sedentary or Increased Alcohol intake or Reduced Activity
Lab Abnormalities
Elevated LFT or increased Cholesterol
Social, Emotional or Other Problems Pertinent to the Case
Depression or Anxiety or Lack of health insurance
Pertinent Physical Findings
Enlarged Liver or Abdominal Mass
Significant Family History
Strong family history of diabetes or Heart Disease
Health Care Maintenance
Good or Not up to date
Status of Assessment:
Acute, Stable, Improving, not responding to treatment
Differentials and Rule Outs:
All the different possibilities that it could be
Cough unknown Etiology
- differential – Bronchitis, Viral Syndrome, Flu
- Cough – Probable Pneumonia, Viral vs. bacterial
- Cough – Probable Viral, consider bacterial
- Cough – R/O Pneumonia (tests orders)
Lab Abnormalities:
- Elevated LFT unknown Etiology Differential: hepatitis, secondary to increased alcohol intake, consider drug reaction
- Elevated LFT – Rule out Hepatitis
Pertinent Physical Finding
- Abdominal Mass unknown Etiology – Differential: Enlarged liver or other organ, impacted stool, intestinal obstruction
PLAN:
“In Consultation with MD” – ALWAYS WRITE ON CHART
Plan for each assessment
Plan has 4 parts:
- Work- up: Labs, X-Rays
- Treatment: Rx, OTC drugs, etc.
- Patient Education: Regarding Dx, labs, etc.
- Follow-up: Next appt or when to return sooner, when you will call with results, referrals, step-wise plan for future visits. (if next visit not better – plan to)
SIGNATURES:
Your Signature
Shaun A. Frost PA-S/Dr. Smith
Dr. Countersign & Date
PROBLEM LIST:
Assessments transferred to problem list
All problems – Medical, Social, Psych, Risk Factors, Health Care, etc.
MEDICATION LIST:
All medications taken
(Usually all medications – cross off when completed)