Focused Visit Assessment and Plan 2024 PDF

The Focused Visit/ The Assessment and Plan Lauren Clemmons, DO, FACOFP Objectives Describe how a focused visit differs from a full history and physical. Obtain a focused patient history for a given chief complaint. Perform a focused physical exam for a given chief complaint. Develo...

The Focused Visit/ The Assessment and Plan Lauren Clemmons, DO, FACOFP Objectives Describe how a focused visit differs from a full history and physical. Obtain a focused patient history for a given chief complaint. Perform a focused physical exam for a given chief complaint. Develop an assessment and plan for a given clinical scenario. Present an assessment and plan to a standardized patient in layman’s terms. Document an assessment and plan in NBOME-style SOAP note format. Describe expectations for next Thursday’s Clinical Reasoning Event. Describe expectations for the next FOSCE and OSCE. Full History and Physical (H&P) Used for: New Patient in Clinic Hospital Admission Annual Physical More thorough: More detailed history 3 generation FH Full ROS Full Exam Allows subsequent encounters/documentation to be shorter/faster. You took a Full History first semester! Focused Visit Used for: Established Patients Follow-up visits The rest of your OSCEs! (Slightly) Less thorough: Less detailed history Focused FH Focused ROS Focused Exam You focus in on what you need to evaluate the chief complaint. You still do all the parts- CC, HPI, PMH, FH, SH… In a real clinic setting, you may be able to get a lot of information from the chart and just confirm with the patient that nothing has changed. “Let’s review your medications and make sure that the list I have is correct.”  You will be conducting a focused visit individually with an SP in the PES area Thursday, May 2nd, so let’s go through the steps! This is what we’ve been practicing in the Small Group case sessions. J The patient Thursday will have a specific joint pain as their chief complaint. Focused History ID CC “Is there anything else you’d like to discuss…?” Pt-Centered Try to really have a conversation here! You actually know some How is it affecting them? diagnoses now!! This should feel What worries them? different than in the Fall. Not just going through the motions. OPPQRRSTA Acute or gradual? Worsening? Review HPI and What’s associated? Approach to… lectures. Really pay attention to each answer! Ask as many questions as you need to for each letter! Focused History Past Medical History (“SMASH”) Significant Medical Problems Medications Allergies Surgeries How does each answer help you? Hospitalizations/ER visits (or not help you?) Social History Review PMH and Approach to… Tobacco/Alcohol/Drugs lectures. What else for this case?? Family History How do you want to approach Family History? Does anything run in your family? Does anyone in your family have bone or joint problems? Does anyone in your family have arthritis? … Focused History Review ROS and Approach to… lectures. Review of Systems Ask questions that will help you “rule in” or “rule out” the diagnoses that are in your differential for the chief complaint Ask as many questions as you need to! Ask about the joint itself. Ask about the other joints. Ask about muscles. Ask neuro. Ask other systems as needed. Focused Physical Exam Not so focused that you just do one test!!! Focused means you don’t have to do a full MSK exam of all four extremities. You can focus in on the joint in question. Example: Patient with sports injury. Heard a pop and knee swelled immediately. Focused exam is not just an anterior drawer! You should inspect, palpate, motion test, and strength test and then do “special tests.” Compare to the knee that isn’t injured also. In most cases, you should also examine the joint above and below. Don’t forget everything you’ve learned in OPP! Always incorporate osteopathic assessment into your physical exam. Review Approach to… lectures. Assessment - What you think or know is wrong with the patient. Can be: working diagnosis problem list reason for visit differential diagnosis (NBOME) 90% of the time diagnosis can be reached by history plus physical. Assessment- working diagnosis (real world) Assessment Assessment Be specific IF 1. Migraine headache you’re sure. 1. Fatigue, suspect anemia Be less specific if you’re less sure. Assessment Assessment 1. B12 deficiency anemia, secondary 1. Inflammatory Arthritis, suspect rheumatoid to vegan diet (was iron def) Assessment Assessment 1. CVA, ischemic vs hemorrhagic 1. Rheumatoid Arthritis Assessment Assessment 1. Hemarthrosis, suspect hemophilia 1. Von Willebrand Disease Assessment Assessment 1. Fatigue This usually means you didn’t do a good You may have history and physical OR you don’t want 1. Giant Cell Arteritis Assessment more than one. anything going in the insurance records yet. 2. Polymyalgia Rheumatica 1. Headache Assessment- problem list (real world) Assessment Assessment 1. Hypertension 1. Systemic lupus erythematosus (M32) 2. Diabetes 2. Long term current use of plaquenil (Z79.899) 3. Hyperlipidemia 3. Anemia of chronic disease (D63.8) 4. Obesity 5. Tobacco Use Disorder Assessment- reason for visit (real world) Assessment 1. Sports physical 2. Alcohol prevention counseling 3. Drug use prevention counseling Asthma action plan 4. STD counseling Breast feeding counseling 5. Injury prevention counseling Counseling about in-the-home gun safety done Counseling for parent child relationship problem Diabetes mellitus counseling Discussion of advance directive Assessment Nutrition and exercise counseling 1. Annual Physical Exam Immunization counseling 2. Obesity Medication counseling 3. Weight loss counseling https://www.icd10data.com/ Assessment- differential diagnosis (NBOME) All OSCE SOAP Notes NOTE: This may change in the future. Assessment- differential diagnosis (NBOME) Assessment- differential diagnosis (NBOME) Example: Patient presents with a chief complaint of “I feel really tired.” He has been a vegan for 7 years. He has been forgetful and has paresthesias of the distal extremities. He has conjunctival pallor and a beefy red tongue on exam. Assessment Please note: 2. and 3. 1. Anemia (plausible diagnosis) only have to be 2. Depression (diagnostic possibility for presenting problem (fatigue)) possibilities for the presenting problem. 3. Fibromyalgia (diagnostic possibility for presenting problem (fatigue)) They can (and likely will be) Assessment diagnoses you have ruled 1. B12 deficiency anemia (plausible diagnosis) out by the end of your history and physical. 2. Iron deficiency anemia (diagnostic possibility for presenting problem (fatigue)) 3. Anemia of chronic disease (diagnostic possibility for presenting problem (fatigue)) Assessment- in the room Give patient the most likely diagnosis. Sometimes the diagnosis is not completely clear, and it may be more appropriate to discuss the differential diagnosis. If the most likely diagnosis is clear, you do not have to discuss diagnoses #2 and #3 that will go in your SOAP note. If there is a diagnosis the patient was worried about and you have excluded it, by all means, tell them!! Patient worried about brain tumor, but they have a classic migraine. Use words and descriptions the patients can understand. Ask if the patient understands and whether they have questions. Assessment- in the room Example: If you feel confident you know the diagnosis, go ahead and tell the patient what it is. “Samantha, I think you have a disorder called von Willebrand disease.” Ideally, give a brief explanation in layman’s terms. “In this disease, your body doesn’t make enough of a protein that you need to help your blood clot the way it should. That is likely why you have always had heavy periods and bruised easily and it also would explain why you have been bleeding after your tonsillectomy.” If there is a diagnosis the patient was worried about and you have excluded it, by all means, tell them!! “I know you were worried about hemophilia since that runs in your friend’s family. Fortunately, your case does not sound like hemophilia. Usually that presents at a much younger age with uncontrollable bleeding and bleeding into your joints. Since you have had mainly bruising problems, that diagnosis is much less likely.” From Bates: Cognitive psychologists have shown that clinicians use three types of reasoning for clinical problem solving: Pattern recognition Development of schemas A schema describes a pattern of thought or behavior that organizes categories of information and the relationships among them. It can also be described as a mental structure of preconceived ideas, a framework representing some aspect of the world, or a system of organizing and perceiving new information. Schemas can also be remarkably difficult to change. Application of relevant basic and clinical science.– As you gain experience, your clinical reasoning will begin at the outset of the patient encounter, not at the end. Once you’ve made your Assessment, you can now make a Plan… Diagnostic and Treatment Plan Confirm the diagnosis/rule out a “can’t miss” diagnosis What information do you need that you don’t already know? Treat suspected diagnosis Patient education Follow-up Shared decision-making Patient-centered Introducing choices and describing options Exploring patient preferences Moving to a decision Plan – May Include Labs Referral Therapy Durable medical equipment Social services Home health Medications Work excuse/restrictions Exercise Instructions for patient self-monitoring Nutrition Providing written information, resources OMT Physical examination Imaging Lifestyle changes Counseling Follow-up Procedures Procedure Notes* Plan Document a plan for each problem Diagnosis, treatment, and patient education May have a range of variations and options Communication and coordination among professionals Follow-up Always give the patient a follow-up plan in the room AND Document it in your note Errors in communication regarding follow-up can lead to bad outcomes Specific: “If you still have a fever Wednesday morning, please Vague: call and ask to speak to my nurse.” “We definitely want to know if OR you don’t get better.” “The antidepressant can take up to 6 weeks to really OR VS. take effect. My nurse will call you in about 10 days to “We’ll follow-up and make make sure that you are tolerating the medication and I sure the treatment is want you to schedule an appointment with me in 6 working.” weeks to see if your depression is improving. You should also call us at any time if you feel your depression is worsening or if you have thoughts of hurting yourself.” Sample Plans Migraine headaches—now down to one to two Cystocele with occasional stress incontinence— per month due to reductions in caffeinated stress incontinence improved with Kegel beverages and stress. Headaches are exercises but still with some urine leakage. responding to NSAIDs. Urinalysis from last visit—no infection. Will defer daily prophylactic medication for now Initiate vaginal estrogen cream. because patient is having fewer than three Continue Kegel exercises. headaches per month and feels better. Affirm need to stop smoking and to continue Follow-up in 3 months. exercise program. Affirm patient's participation in support group to Occasional low back pain—no complaints today. reduce stress. Follow-up in 3 months or sooner if headache frequency increases. Tobacco abuse—desiring medication-assisted smoking cessation. Elevated blood pressure—BP remains elevated Will start nicotine patches. at 150/90. Follow-up in 1 month. Will initiate therapy with a diuretic. Patient to take blood pressure three times a week at Health maintenance home and bring recordings to next office visit. Pap smear sent last visit. Follow-up in 3 weeks. Mammogram scheduled. Colonoscopy recommended, patient declines today. Overweight—has lost ∼4 lbs. Follow-up in 1 year. Continue exercise. Review diet history; affirm weight reduction. Follow-up in 3 months. Sample Plans Von Willebrand disease: For a case with suspected disease: CBC aPTT vWF Ag Ristocetin cofactor test Desmopressin and oral contraceptives if indicated For the case with labs back: Administer IV vWF concentrate and monitor bleeding Consult ENT Consult hematology Consider desmopressin Plan NBOME Example Plan Closing the Visit Answer any questions “Teach back” New concerns? Health Care Communication Module: Provide Closure is a nice short module on how to close the encounter well. You may wish to review that for additional guidance. Clinical Reasoning Event Report to OPP Lab or SIM Lab for Student Waiting. Professional attire/white coat. 8 minutes in the exam room to take a FOCUSED patient history. Step out to the SOAP note area and decide what physical exam you should do. You are welcome to talk softly to the student nearest you about what exams to do. 8 minutes to decide. 8 minutes back into the exam room to conduct your physical exam. You are welcome to give the patient an assessment and plan if time allows. This is good practice for FOSCE/OSCE. Do NOT perform OMT. SOAP note documentation on your own between the encounter and debrief. Debrief in Auditorium. May FOSCE and OSCE Thursday’s event is a warm-up exercise for the FOSCE and subsequent OSCE. 18-minute focused encounter followed by SOAP note. You will give the patient the Assessment and Plan in the room. The FOSCE will be non-graded and will be followed by immediate individualized feedback. Cases for the FOSCE and for the OSCE will be from a system you’ve had this semester- Neuro, MSK, or Heme-Lymph. The PCS 'Approach to' PowerPoints used in conjunction with each system should be helpful in preparing. We also suggest that you practice with classmates to keep your interview and physical exam skills intact.  (F)OSCE A good rule of thumb is to start your Assessment and Plan at the 2-minute warning if you haven’t already. Discuss diagnostic possibilities with the patient- either a working diagnosis or a differential diagnosis. If you feel confident you know the diagnosis, go ahead and tell the patient what it is. Give the explanation in layman’s terms. If there are several diagnoses that you are still strongly considering, you should tell the patient all of those. Discuss an appropriate plan with the patient including follow-up. Ask if patient has questions. Orient your patient to the end of the interview and offer support before saying goodbye. “I appreciate you coming in today and I certainly hope that this plan gets your shoulder feeling much better." References Bickley, Lynn S., et al. Bates' Guide to Physical Examination and History Taking. 13th ed., Wolters Kluwer, 2021. https://www.nbome.org/C3DO/updates/ Health Care Communication Module: Provide Closure Questions? General course or grading questions? ACOM PCS Course Director email: [email protected] Office hours available by appointment: Lauren Clemmons, DO, FACOFP [email protected] 35