Podcast
Questions and Answers
Why is the separation of assessment and plan recommended, despite alternative methods?
Why is the separation of assessment and plan recommended, despite alternative methods?
- It aligns with billing and coding requirements for accurate reimbursement.
- It is universally accepted as the superior method in all medical settings.
- It provides a structured approach for identifying key information and communicating patient status effectively. (correct)
- It reduces the amount of documentation required, saving time for healthcare providers.
Which of the following best explains the role of pertinent negatives within the subjective portion of a patient assessment?
Which of the following best explains the role of pertinent negatives within the subjective portion of a patient assessment?
- They rule out potentially serious conditions, guiding diagnostic and treatment decisions. (correct)
- They confirm the presence of specific symptoms, supporting a particular diagnosis.
- They quantify the severity of the patient's symptoms using objective measurements.
- They document aspects of the patient's medical history that are irrelevant to the current presentation.
In constructing the 'subjective' portion of the assessment, what is the primary goal when including details from the patient's history?
In constructing the 'subjective' portion of the assessment, what is the primary goal when including details from the patient's history?
- Selectively include historical elements that directly influence the current presentation and potential diagnoses. (correct)
- Omit any historical information to maintain focus on the present symptoms.
- Record all historical data to ensure a comprehensive patient profile.
- Prioritize historical information based on its chronological order.
How should problems be prioritized in the 'plan' component of the assessment?
How should problems be prioritized in the 'plan' component of the assessment?
What is the most important reason for structuring an assessment in the described manner?
What is the most important reason for structuring an assessment in the described manner?
When presenting a patient case to a preceptor with limited time, which information should be prioritized, according to the recommended assessment structure?
When presenting a patient case to a preceptor with limited time, which information should be prioritized, according to the recommended assessment structure?
Which of the following reflects the appropriate order of elements within the recommended assessment structure?
Which of the following reflects the appropriate order of elements within the recommended assessment structure?
In the context of the provided material, what is the most significant reason for including specific directives related to patient care in the 'plan' component?
In the context of the provided material, what is the most significant reason for including specific directives related to patient care in the 'plan' component?
Given a patient presenting with chest pain, which objective finding would most strongly influence the prioritization of 'acute myocardial infarction' in the differential diagnosis?
Given a patient presenting with chest pain, which objective finding would most strongly influence the prioritization of 'acute myocardial infarction' in the differential diagnosis?
When incorporating a patient's past medical history into the assessment, what principle should guide the selection of information to include?
When incorporating a patient's past medical history into the assessment, what principle should guide the selection of information to include?
Flashcards
Assessment (Medical)
Assessment (Medical)
A concise summary of the most important subjective and objective patient information, followed by a list of potential diagnoses.
Plan (Medical)
Plan (Medical)
Specific instructions for patient care, including diagnostic tests, treatments, and consultations, organized by priority.
Subjective Information
Subjective Information
Information reported by the patient, such as symptoms, history, and feelings.
Objective Information
Objective Information
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Differential Diagnoses
Differential Diagnoses
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Chief Complaint
Chief Complaint
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History of Present Illness (HPI)
History of Present Illness (HPI)
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Review of Systems (ROS)
Review of Systems (ROS)
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Pertinent Negatives
Pertinent Negatives
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Pertinent Positives
Pertinent Positives
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Study Notes
- The assessment and plan are separated for specific reasons that will be discussed.
Assessment Components
- A summary of the most important subjective and objective patient information
- Begins with a subjective summary
- Followed by pertinent objective information
- Culminates in differential diagnoses
Subjective Summary
- Includes key details:
- Patient identity
- Duration of complaint
- Factors that worsen or improve the condition
- Associated symptoms
- Pertinent negatives, such as absence of fever and chills
- Pertinent positives, such as chest pain, shortness of breath, leg swelling, and nausea
Objective Information
- Vital signs should always be commented on
- Note if stable, normal, or abnormal
- Highlight values of particular concern
- Other findings that may be important:
- Patient's weight status
- Jugular venous distension
- Heart sounds
- Lung sounds (rails or crackles)
- Edema in lower extremities
Consolidating Subjective and Objective Data
- Subjective example: "Mr. Jones is a 65-year-old male with a past medical history of hypertension and uncontrolled type 2 diabetes, who presents with one day of worsening chest pain, nausea, and diaphoresis."
- Objective example: "He is afebrile with a blood pressure of 110/70, heart rate of 88, bilateral rails, JVD, and bilateral pitting edema in the lower extremities."
- Differential diagnoses may include: acute myocardial infarction, congestive heart failure, and pulmonary embolism.
Plan
- Includes specific directives for patient care:
- Diagnostic tests
- Treatments
- Consultations
- Care instructions
- Problem-based manner, listing each problem by priority
- Acute items are listed first
- Chronic medical problems are placed towards the end
Assessment and Plan Example
- Assessment: A 65-year-old, overweight male with a history of hypertension and type 2 diabetes presents with one day of chest pain and shortness of breath that worsens with exertion, nausea, and sweating. Examination reveals stable vital signs, an S3 heart sound, JVD, rails, and lower extremity edema. Differential includes myocardial infarction, congestive heart failure, and pulmonary embolism.
- Plan: Addresses the chief complaint of chest pain. Includes diagnostic workup (CBC, CMP, serial cardiac enzymes, BNP, D-dimer, CXR), potential treatments, admission plans, and consultations, if appropriate. Also addresses less important items or chronic conditions that need attention during patient care.
Rationale
- Helps identify the most important subjective and objective information for patient care.
- Enables effective communication with preceptors by providing a concise summary statement of the patient's condition, exam findings, and potential diagnoses. The preceptor can request additional information from the history and physical as required.
Summary
- Assessment: a summary statement of the most important subjective and objective information, including pertinent differential diagnoses.
- Plan: an itemized list of how the patient will be cared for, including diagnostic tests, treatments, and consultations.
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