Elements of a clinical history
Download
1 / 31

ELEMENTS OF A CLINICAL HISTORY - PowerPoint PPT Presentation


  • 112 Views
  • Uploaded on

ELEMENTS OF A CLINICAL HISTORY. The sacred seven Helen Murphy RT(R). Localization. This is defined as the exact area of the patient’s complaint. *Ask: Where does it hurt, could you point to it for me? * left or right, anterior or posterior, medial or lateral, upper or lower

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'ELEMENTS OF A CLINICAL HISTORY' - drago


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Elements of a clinical history

ELEMENTS OF A CLINICAL HISTORY

The sacred seven

Helen Murphy RT(R)


Localization
Localization

  • This is defined as the exact area of the patient’s complaint.

    *Ask: Where does it hurt, could you point to it for me?

    * left or right, anterior or posterior,

    medial or lateral, upper or lower

    *name the part: ankle, hand, finger etc..

    *Write : Posterior upper neck pain.


Chronology
Chronology

  • The arrangement of events in time.

    *Ask : when did this happen?

    *Write: Stiff neck and decreased range of motion after motor vehicle accident three days ago.

    * write date out 28 September 2011


Quality
Quality

This describes the character of symptoms.

* chronic, acute, throbbing, sharp, dull, aching, burning, radiation, pressure.

*Ask: What does it feel like?

*Write : Sharp pain down both arms.


Severity
Severity

  • This describes the intensity, quantity or extensiveness of the problem.

    * Ask : On a scale of one to ten how would you rate your pain?

    * pain rating was a ten but post medications it’s now a four.



Onset
Onset

  • This relates to when the symptoms began and/or what the patient was doing at the time the symptoms began.

    * Ask : What were you doing when this happen?

    * Write: Sudden onset headache with no known injury.


Aggravating or alleviating factors
Aggravating or alleviating factors

  • Circumstances that intensify or diminish the condition.

    *Ask: Does anything make the pain better or worse?


Aggravating or alleviating factors1
Aggravating or alleviating factors

* Write: Pain greater with flexion and extension.

* Write: Headache is greater when lights are on.


Associated manifestations
Associated Manifestations

What, if any, symptoms accompany the chief complaint.

*Write: Posterior upper neck pain with right arm numbness when patient raises arms above head.

*Write: Nausea and vomiting when upright.


History for c spine
History: for c-spine

Posterior upper neck pain. Motor vehicle accident three days ago now has stiff neck and decreased range of motion. Sharp pain down both arms with numbness. Pain rating was a ten but post medication it’s now a four. Pain greater with flexion and extension.


Two reasons we need a good hx
Two reasons we need a good HX

First the radiologist depends on the clinical histories that we provide to aid in the interpretations. We see the patients they do not!


Elements of a clinical history

Helen,

FYI for students: Please see the note below from Dr McCabe.  This is the same information we provided on the requisitions in the past, just in the online form now.  The more information we can supply the better!

Karen

A large percentage of fluoro studies of the spine that are read by the neuro section are missing either the fluoro time, the contrast amount, or both. The most commonly involved studies are the facet joint and epidural injections. This causes delays in dictating and more work for everyone involved. I would like to start having the fluoro tech fill out both of these sections in the online form (OLF). If there is no contrast used, then a '0' or 'none' would be placed in the text box. By consistently filling out both boxes, the hope is that there will be less wasted time and subsequent production loss. Thank you for your attention to this matter. Please respond with any questions or concerns. Ken McCabe

Helen,

FYI for students: Please see the note below from Dr Lewis.

 Karen

We are still getting crap for histories on the OLF’s. The point of the OLF is to have a meaningful history, properly spelled and grammatically correct so it can be dropped into the report as written on the form. This never happens from SHMC, particularly from the ICU portables. ‘Patient is on a ventilator’ is not a billable history. SHMC is throwing money down the toilet if we choose to use this history and/or decreasing our efficiency by making us come up with some plausible history on studies if we choose not to use the junk provided. Dr Lewis


Elements of a clinical history
Second we also need it to bill the patient correctly so we will get full reimbursement from the insurance companies.


Places to find a hx
Places to find a HX will get full reimbursement from the insurance companies.

  • Inpatient

  • * in the chart

  • - H&P

  • - Progress notes

  • - Docotor’s orders


Past medical history or history and physical h p
Past medical history or history and physical ( H&P) will get full reimbursement from the insurance companies.

This is a form that must be in the patients chart before entering a procedure/OR room (H&P can’t be more then 30 days old)


Progress note
Progress note: will get full reimbursement from the insurance companies.

The Dr and/or nurse may make notes regarding the patient's condition and onset or continuation of symptoms.


Doctor s orders
DOCTOR’S ORDERS will get full reimbursement from the insurance companies.

This will have the exam order and sometimes a history.


Out patient
Out patient will get full reimbursement from the insurance companies.

*Check the order for history.

*You might have to ask patient for more history then what is given.


Er patients
ER patients will get full reimbursement from the insurance companies.

*There is no chart with this patient.

*There sometimes is no written order with the patient.( SHMC pink slip with patients but you can’t read them)

* Check Meditech

*It is up to you to make sure you are doing the correct exam.

*Talk to ER doctor.


Symptoms vs diagnosis
Symptoms VS Diagnosis will get full reimbursement from the insurance companies.

The symptoms that a patient is exhibiting or complaining of may not match the original diagnosis.


Reasons for exams
Reasons for Exams will get full reimbursement from the insurance companies.

Finding the reason for an exam may be more difficult for some exams than others.


Reasons for a cxr
Reasons for a CXR will get full reimbursement from the insurance companies.

  • Chest pain

  • Shortness of breath (SOB)

  • Cough

  • Fever

  • History of cancer (Ca)

  • History of stroke

  • COPD (chronic obstructive pulmonary disease)

  • CAD (coronary artery disease)

  • History of smoking

  • Prior History of heart or lung problems (high blood pressure)

  • Diabetes

  • Renal failure

  • Pre-Operative


To ask cxr patient
? To ask CXR patient: will get full reimbursement from the insurance companies.

  • Do you smoke?

  • Do you have any difficulty breathing?

  • Are you ever short of breath?

  • Have you had pneumonia?

  • Do you have emphysema or asthma?

  • Have you had a cold, the flu, a fever

    or sinus infection recently? When?


Pre op is not a symptom or diagnosis

PRE-OP is not a Symptom or Diagnosis!!! will get full reimbursement from the insurance companies.


Confidentiality
Confidentiality will get full reimbursement from the insurance companies.

  • Here we go again!!!!

  • Medical information is confidential

  • Do we need to know all the patient health information (HIPAA)?


The bare minimum
The bare minimum will get full reimbursement from the insurance companies.

The very least that you need to have if all else fails is the patients symptoms and how long they have been present.

Short of breath for the last three days.