Cardiac System Assessment and Diagnosis

Cardiac System and Medical Documentation

• A patient's denial of cardiac stents is documented in the History - Subjective section, under Chief Complaint and History of Present Illness (HPI).

Medical Documentation Structure

• Chief Complaint: patient's primary concern
• History - Subjective: patient's reported information, including HPI, past medical history, and review of systems (ROS)
• Objective: exam findings, laboratory results, and available images
• Assessment: diagnosis, including primary and differential diagnoses
• Plan: treatment plan, including prescriptions, imaging or diagnostic procedures, and follow-up care

Types of Medical Encounters

• Comprehensive History and Physical (H&P): most detailed and comprehensive, used for new patients or baseline assessments
• Focused Encounter: established patient with a specific chief complaint, tailored exam and documentation
• Focused Follow-up: established patient with a specific concern, follow-up visit
• Focused Emergency: urgent visit, prioritizing acute concern over comprehensive assessment

Comprehensive History and Physical (H&P)

• Introductory Information: patient demographics, including gender, race, ethnicity, language, and accompaniment
• Past Medical History: surgical, psychiatric, and developmental history, current medications, and current health conditions
• Social, Occupational, and Family History: including genetic or hereditary risk factors (e.g., cardiac disease, psychiatric illness, cancer, hypertension, diabetes)

Quiz about evaluating and diagnosing cardiac conditions, including history taking, physical examination, and laboratory results. Test your knowledge of cardiac assessment and diagnosis.