Transcript elements of a clinical history

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
*name the part: ankle, hand, finger
etc..
*Write : Posterior upper neck pain.
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
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
 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.
Severity
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
 Circumstances that intensify or
diminish the condition.
*Ask: Does anything make the pain
better or worse?
Aggravating or alleviating factors
* Write: Pain greater with flexion
and extension.
* Write: Headache is greater when
lights are on.
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
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
First the radiologist depends
on the clinical histories that
we provide to aid in the
interpretations. We see the
patients they do not!
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
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
A. Inpatient
* in the chart
- H&P
- Progress notes
- Docotor’s orders
Past medical history or history and
physical ( H&P)
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:
The Dr and/or nurse may make notes
regarding the patient's condition and
onset or continuation of symptoms.
DOCTOR’S ORDERS
This will have the exam order and
sometimes a history.
Out patient
*Check the order for history.
*You might have to ask patient for
more history then what is given.
ER patients
*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
The symptoms that a patient is
exhibiting or complaining of may not
match the original diagnosis.
Reasons for Exams
Finding the reason for an exam may
be more difficult for some exams than
others.
Reasons for a CXR
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
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:
1.
2.
3.
4.
5.
6.
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!!!
Confidentiality
• Here we go again!!!!
• Medical information is confidential
• Do we need to know all the patient
health information (HIPAA)?
The bare minimum
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.