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
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The sacred seven
Helen Murphy RT(R)
*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.
*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
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.
* 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.
* Ask : What were you doing when this happen?
* Write: Sudden onset headache with no known injury.
*Ask: Does anything make the pain better or worse?
* Write: Pain greater with flexion and extension.
* Write: Headache is greater when lights are on.
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.
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.
First the radiologist depends on the clinical histories that we provide to aid in the interpretations. We see the patients they do not!
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!
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
FYI for students: Please see the note below from Dr Lewis.
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
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)
The Dr and/or nurse may make notes regarding the patient's condition and onset or continuation of symptoms.
This will have the exam order and sometimes a history.
*Check the order for history.
*You might have to ask patient for more history then what is given.
*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.
The symptoms that a patient is exhibiting or complaining of may not match the original diagnosis.
Finding the reason for an exam may be more difficult for some exams than others.
or sinus infection recently? When?
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.