NRNP-6531 11 Practice Care Adult across Life Mid Term Exam
PQRST
P—palliative or provocative factors
Q—quality of pain
R—region affected
S—severity of pain
T—timing
LOCATES
L—location
O—onset
C—character
A—associated signs and symptoms
T—timing
E—exacerbating/relieving factors
S—severity
OLD CHARTS
O—onset
L—location
D—duration
CH—character
A—alleviating/aggravating
R—radiation
T—temporal pattern
S—symptoms associated
COLDERAS
C—character
O—onset
L—location
D—duration
E—exacerbating factors
R—relieving factors
A—associated signs and symptoms
S—severity
LIQORAAA
L—location
I—intensity
Q—quality
O—onset
R—radiation
A—associated signs and symptoms
A—alleviating factors
A—aggravating factors
QFLORIDAA
Q—quality
F—frequency
L—location
O—onset
R—radiation
I—intensity
D—duration
A—alleviating/aggravating
A—associated signs and symptom
Past Medical History
Use the past medical history (PMH) section to document the patient’s past and current health. Document when each condition was diagnosed, and indicate its present status, such as stable, uncontrolled, or resolved.
You may subdivide information in the PMH into past medical history, past surgical history or other hospitalizations, medications, drug allergies, and health maintenance and immunizations.
History of Present Illness Mnemonics
PQRST
P—palliative or provocative factors
Q—quality of pain
R—region affected
S—severity of pain
T—timing
LOCATES
L—location
O—onset
C—character
A—associated signs and symptoms
T—timing
E—exacerbating/relieving factors
S—severity
OLD CHARTS
O—onset
L—location
D—duration
CH—character
A—alleviating/aggravating
R—radiation
T—temporal pattern
S—symptoms associated
COLDERAS
C—character
O—onset
L—location
D—duration
E—exacerbating factors
R—relieving factors
A—associated signs and symptoms
S—severity
LIQORAAA
L—location
I—intensity
Q—quality
O—onset
R—radiation
A—associated signs and symptoms
A—alleviating factors
A—aggravating factors
QFLORIDAA
Q—quality
F—frequency
L—location
O—onset
R—radiation
I—intensity
D—duration
A—alleviating/aggravating
A—associated signs and symptom
Past Medical History
Use the past medical history (PMH) section to document the patient’s past and current health. Document when each condition was diagnosed, and indicate its present status, such as stable, uncontrolled, or resolved.
You may subdivide information in the PMH into past medical history, past surgical history or other hospitalizations, medications, drug allergies, and health maintenance and immunizations.
Using subheadings within the PMH, as shown in Table 2-3, makes it easier to locate information and identify the change from one topic to another.
Table 2-3 Subheadings Used for Past Medical History
- Past Medical History
- Medical
- Surgical/hospitalizations
- Medications
- Allergies
- Health maintenance/immunizations
if the patient has multiple medical problems, it may be helpful to document them as an enumerated list rather than in paragraph format. If the patient has had any surgery or hospitalizations for major trauma or other reasons, be sure to include the type of operation and date of the surgery; if known, you can include the name of the doctor who performed the surgery.
You should document a medication list as part of the PMH. This includes both prescription medications and over-the-counter products, such as herbal supplements, vitamins, minerals, and dietary supplements.
Be sure to include the name of the medication, the dose, how frequently it is taken, and ideally, why the patient takes the medication. Review the list of medications with the patient at every visit to ensure accuracy.
It is extremely important to document any drug allergies the patient has. You may document food allergies in this section also.
You should document the specific reaction the patient experiences when the food or drug is ingested. In most settings, there will be a specific way to indicate a drug allergy, such as a special sticker affixed to the front of the patient’s chart, so that it is not overlooked.
In an electronic medical record (EMR), the text may be a different color or there may be a special tab or menu bar to highlight any allergies.
It is critically important to inquire specifically about and document an allergy to latex. A patient with a latex allergy will need special equipment.
You should document environmental allergies, such as an allergy to cats that results in allergic rhinitis, in the PMH. If the patient is treated regularly for allergy-related conditions, document these conditions under the heading of Medical Conditions rather than Allergies.
The health maintenance and immunization section of the PMH will vary according to the patient’s age and gender. Chapters 5, 6, and 7 discuss documentation of health maintenance activities and immunizations in the pediatric, adult, and older adult patient, respectively.
Family History
Typically, you should document the medical history of first-degree relatives, that is, the family history (FH) for parents, grandparents, siblings, and children.
Remember that a spouse’s medical history is not considered part of the patient’s FH, although it may be applicable in situations in which a couple presents because of infertility or genetic counseling.
Document the age and status (living, deceased, health status) of the first-degree relatives. If those relatives are deceased, include the age at time of death and cause of death.
If the relatives are still living, document their current age and medical conditions, paying particular attention to those conditions that have a familial tendency such as cardiovascular disease, diabetes, and certain cancers, osteoporosis, and sleep apnea.
Also determine whether any first-degree relatives have or had the condition with which the patient is presenting. In addition to medical conditions, inquire about any substance abuse, addictions, depression, or other mental health conditions of family members.
Social History
One of the main goals of documenting the social history (SH) of the patient is to identify factors outside of past or current medical conditions that may influence the patient’s overall health or behaviors that create risk factors for specific conditions.
These risk factors include use of tobacco, alcohol, and drugs. If these risk factors are present, document quantity of use and how long the use has occurred. Smoking history should include number of packs per day and the number of years the patient has smoked.
If the patient formerly smoked or used smokeless tobacco, you still should document the details of the tobacco use with the addition of how long it has been since the patient quit. Avoid ambiguous terms such as social drinker that do not assist you or other readers in determining whether there is a risk factor associated with substance use.
Typically, the use of illegal substances is documented as drug use, but also you should determine whether the patient is taking substances prescribed for someone else or misusing prescription medication. If a risk factor is identified, be sure to include it in the problem list and assessment and plan.
Age-specific SH is discussed in other chapters. Information about the patient’s sexual orientation, gender identification, marital status, and number of children is included.
Documentation of the patient’s past and current employment may help identify potential occupational hazards. Include any military service and where stationed (stateside or overseas) as well as any possible exposures.
If the patient has lived or traveled abroad, document locations and potential exposures, if any. It is important to document the patient’s educational level and ability to read and write.
If the patient speaks more than one language, you should document which language the patient prefers.
Religion and religious and cultural beliefs may have an impact on a patient’s overall health. It can be difficult to determine the difference between a religious belief and a cultural belief, although typically it is not necessary to do so.
Specific documentation of the religious and cultural history includes beliefs related to health and illness, family, symbols, nutrition, special events, spirituality, and taboos. Table 2-4 shows questions that you can ask as part of the religious and cultural history. NRNP-6531 11 Practice Care Adult across Life Mid Term Exam
Table 2-4Questions to Ask for Cultural and Religious History
Communication
- Is a translator needed?
- What is your primary oral language?
- What is your primary written language?
Beliefs Affecting Health and Illness
- What do you think caused your illness or condition?
- How does it affect your life?
- Have you seen anyone else about this problem?
- If yes, who?
- Have you used any home remedies for your problem?
- If yes, what?
- Are you willing to take prescription medications?
- Are you willing to use alternative therapies, such as herbal medicine?
Family
- Definition of family
- Roles within family
- Who has authority for decision-making related to your health care?
Symbols
- Special clothing
- Ritualistic and religious articles
Nutrition
- Specific food rituals
- Specific food avoidances
- Major foods
- Preparation practices
Special Events
- Prenatal care
- Death and burial rituals
- Beliefs of afterlife
- Willing to accept blood transfusions?
- Willing to accept organ transplantation?
- Organ, blood, or tissue donor?
Spirituality
- Dominant religion
- Active participant?
- Prayer and meditation
- Special activities
- Relationship between spiritual beliefs and health practices
Taboos
- Describe any taboos that would affect health care
Document nutritional information in terms of type of diet the patient follows, caffeine intake, and food allergies or avoidances. If there are questions or concerns about a patient’s diet, it may be helpful to record a “typical day” or “last 24 hours” of food intake.
Sedentary lifestyle is a risk factor for certain diseases, so document whether the patient exercises. If the patient exercises, include the type, frequency, and duration of exercise.
One basic consideration of a patient’s ability to access health care is whether the patient has health-care insurance or some other form of payment, such as Social Security or workers’ compensation. NRNP-6531 11 Practice Care Adult across Life Mid Term Exam
Although financial records generally should be kept separate from the medical records, you should document whether the patient is insured or uninsured. If uninsured, information about income or ability to self-pay becomes essential.
The provision or lack of insurance will guide many health-care choices, especially related to prescribing medications. Using generic instead of brand-name medications will result in cost savings for the patient and is often medically neutral, meaning the patient should get the same benefit from generic as from brand-name medications.
MEDICOLEGAL ALERT!
Documenting that you have counseled the patient on the risks of negative health habits and the management of chronic disease is an important part of the management of medicolegal risk. Providers have been sued for not providing patient education and counseling.
One such case involved a 33-year-old woman who was obese and hypertensive and smoked. She had frequent visits to the clinic for various complaints.
Routine screening tests revealed marked hypercholesterolemia and an abnormal ratio of high-density lipoprotein (HDL) to low-density lipoprotein (LDL). The health-care provider never counseled the patient regarding her risk for coronary artery disease.
Several years later, the patient presented to an emergency room with crushing chest pain that radiated to her arms and neck. The diagnosis of myocardial infarction was confirmed, but by the time the diagnosis was made, the window of opportunity for thrombolytic therapy had closed.
The patient sued the clinic and the health-care provider for malpractice. The health-care provider was found negligent for not educating and counseling the patient about her risk factors for developing heart disease.
Review of Systems (SUBJECTIVE)
The review of systems (ROS) is an inventory of specific body systems designed to document any symptoms the patient may be experiencing or has experienced.
Typically, you should document both positive symptoms (those the patient has experienced) and negative symptoms (those the patient denies having experienced). A positive response from a patient about any symptom should prompt you to explore all elements of that symptom just as you would for the HPI (location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms).
Rather than asking whether the patient has ever experienced any of the symptoms listed, it is appropriate to limit the review to a specific time frame.
That time frame might change depending on the patient’s CC and HPI; if you are seeing a patient for the first time, it is usually sufficient to ask about the past year. If the patient has been seen before, ask about the time frame since the previous visit. NRNP-6531 11 Practice Care Adult across Life Mid Term Exam
Consistent with the 1995 and 1997 CMS guidelines, 14 systems are identified, and specific symptoms that should be explored in each system are included here. How many symptoms are explored within each system is up to you as indicated by the patient’s presenting complaint.
- Constitutional: these symptoms do not fit specifically with one system but often affect the general well-being or overall status of a patient. Specific symptoms include weight loss, weight gain, fatigue, weakness, fever, chills, and night sweats.
- Eyes: change in vision, date of last visual examination, glasses or contact lenses, history of eye surgery, eye pain, photophobia, diplopia, spots or floaters, discharge, excessive tearing, itching, cataracts, or glaucoma.
- Ears, nose, and mouth/throat (ENT):
- Ears: change in or loss of hearing, date of last auditory evaluation, hearing aids, history of ear surgery, ear pain, tinnitus, drainage from the ear, history of ear infections.
- Nose: changes in or loss of sense of smell, epistaxis, obstruction, polyps, rhinorrhea, itching, sneezing, sinus problems.
- Mouth/throat: date of last dental examination, ulcerations or other lesions of tongue or mucosa, bleeding gums, gingivitis, dentures, or any dental appliances.
- Cardiovascular (CV): chest pain, orthopnea, murmurs, palpitations, arrhythmias, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema, claudication, date of last electrocardiogram or other cardiovascular studies.
- Respiratory: dyspnea, cough, amount and color of sputum, hemoptysis, history of pneumonia, date of last chest radiograph, date and result of last tuberculosis testing.
- Gastrointestinal (GI): abdominal pain; dysphagia; heartburn; nausea; vomiting; usual bowel habits and any change in bowel habits; use of aids such as fiber, laxatives, or stool softeners; melena; hematochezia; hematemesis; hemorrhoids; jaundice.
- Genitourinary (GU): frequency, urgency, dysuria, hematuria, polyuria, incontinence, sexual orientation, number of partners, history of sexually transmitted infections, infertility.
- Males: hesitancy, change in urine stream, nocturia, penile discharge, erectile dysfunction, date of last testicular examination, date of last prostate examination, date and result of last prostate-specific antigen (PSA) test.
- Females: GU symptoms as described previously and gynecological symptoms; age at menarche; gravida, para, abortions; frequency, duration, and flow of menstrual periods; date of last menstrual period; dysmenorrhea; type of contraception used; ability to achieve orgasm; dyspareunia; vaginal dryness, menopause; breast lesions, date and type of last breast imaging; date and result of last Papanicolaou smear, date of last pelvic examination.
- Musculoskeletal (MSK): arthralgias, arthritis, gout, joint swelling, trauma, limitations in range of motion (ROM), back pain. (Note that numbness, tingling, and weakness are typically not included in musculoskeletal but in neurological system.)
- Integumentary: rashes, pruritus, bruising, dryness, skin cancer or other lesions.
- Neurological: syncope, seizures, numbness, tingling, weakness, gait disturbances, coordination problems, altered sensation, alteration in memory, difficulty concentrating, headaches, head trauma, or brain injury. (Headache, head trauma, or brain injury may also be listed under head, as part of Head, Eyes, Ears, Nose, Mouth/Throat, or HEENT.)
- Psychiatric: emotional disturbances, sleep disturbances, substance abuse disorders, hallucinations, illusions, delusions, affective or personality disorders, nervousness or irritability, suicidal ideation or past suicide attempts.
- Endocrine: polyuria, polydipsia, polyphagia, temperature intolerance, hormone therapy, changes in hair or skin texture.
- Hematologic/lymphatic: easy bruising, bleeding tendency, anemia, blood transfusions, thromboembolic disorders, lymphadenopathy.
- Allergic/immunologic: allergic rhinitis, asthma, atopy, food allergies, immunotherapy, frequent or chronic infections, HIV status; if HIV positive, date and result of last CD4 count.
You may use standard forms or templates for gathering much of the history information, and this is certainly an acceptable, time-saving practice.
However, you have an obligation to review and verify the information that the patient provides. Staff members may use the forms to enter information into an EMR. The original paper forms should be scanned into the EMR. NRNP-6531 11 Practice Care Adult across Life Mid Term Exam
Physical Examination (OBJECTIVE)
The rationale for physical examination rests on a basic assumption that there is such a thing as normality of bodily structure and function corresponding to a state of health and that departures from this norm consistently result from or correlate with specific abnormal states or disease.
It is helpful to think about a “range of normal” when it comes to physical examination findings, rather than a single “normal” for every part of the examination.
The physical examination may confirm or refute a diagnosis suspected from the history, and by adding this information to the database, you will be able to construct a more accurate problem list.
Like the history, the physical examination is structured to record both positive and negative findings in detail.
Generally, the examination will proceed in a head-to-toe fashion. In some instances, it may be necessary to deviate from this order, such as performing an invasive component at the end of the examination or examining an area of pain last.
Regardless of the order in which the examination is performed, documentation of the physical examination should follow the order that follows and in Table 2-5.
Consult other textbooks for instruction on how to perform the physical examination and for a discussion on the importance of any findings; here the emphasis is on the documentation of a comprehensive physical examination.
General assessment (OBJECTIVE)
- Vital signs: temperature, pulse, respiration, blood pressure, height, weight, body mass index (BMI)
- Skin
- HEENT
- Neck
- Respiratory
- Cardiovascular
- Abdomen
- Genitourinary or gynecological
- Musculoskeletal
- Neurological
General: age, race, gender, general appearance. Documentation of general appearance could include alertness, orientation, mood, affect, gait, how a patient sits on the examination table or chair, grooming, and the patient’s reliability to provide an adequate history. Document whether the patient is in any distress or whether the patient appears markedly older or younger than the stated age.
OBJECTIVE DATA
- Vital signs: temperature, blood pressure, pulse, respiratory rate, height, weight, and body mass index (BMI).
- Skin: presence and description of any lesions, scars, tattoos, moles, texture, turgor, temperature; hair texture, distribution pattern; nail texture, nail base angle, ridging, pitting.
- HEENT:
- Head (including face): size and contour of head, symmetry of facial features, characteristic facies, tenderness, or bruits of temporal arteries.
- Eyes: conjunctivae; sclera; lids; pupil size, shape, and reactivity; extraocular movement (EOM); nystagmus; visual acuity. Ophthalmoscopic findings of cornea, lens, retina, red reflex, optic disc color and size, cupping, spontaneous venous pulsations, hemorrhages, exudates, nicking, arteriovenous crossings.
- Ears: integrity, color, landmarks, and mobility of the tympanic membranes; tenderness, discharge, external canal, tenderness of auricles, nodules.
- Nose: symmetry, alignment of septum, nasal patency, appearance of turbinates, presence of discharge, polyps, palpation of frontal and maxillary sinuses.
- Mouth/throat: lips, teeth, gums, tongue, buccal mucosa, tonsillar size, exudate, erythema.
- Neck: ROM, cervical and clavicular lymph nodes, thyroid examination, position, and mobility of the trachea.
- Respiratory: effort of breathing, breath sounds, adventitious sounds, chest wall expansion, symmetry of breathing, diaphragmatic excursion.
- Cardiovascular: heart sounds, murmurs or extra sounds, rhythm, point of maximal impulse, peripheral edema, central and peripheral pulses, varicosities, venous hums, bruits.
- Breast: symmetry, inspection for dimpling of skin, nipple discharge, palpation for tenderness, cyst or masses, axillary nodes, gynecomastia in males.
- Abdomen: shape (flat, scaphoid, distended, obese), bowel sounds, masses, organomegaly, tenderness, inguinal nodes.
- Male genitalia or gynecological (breast examination sometimes documented here).
- Male genitalia: hair distribution, nits, testes, scrotum, penis, circumcised or uncircumcised, varicocele, masses, tenderness.
- Gynecological: External inspection of the perineum for lesions, nits, hair distribution, areas of swelling or tenderness, labia and labial folds, Skenes and Bartholin glands, vaginal introitus; noting any discharge or cystocele if present. Internal—inspect vaginal walls and cervix for color, discharge, lesions, bleeding, atrophy; inspect cervical os for size and shape; bimanual examination for size, shape, consistency and mobility of the cervix; cervical motion tenderness, uterine or ovarian enlargement, masses, tenderness, adnexal masses or tenderness.
- Rectal: hemorrhoids, fissures, sphincter tone, masses, rectocele; if stool is present, color and consistency of stool, test stool for occult blood; prostate examination for males, noting size, uniformity, nodules, tenderness.
- Musculoskeletal: symmetry of upper and lower extremities, ROM of joints, joint swelling, redness or tenderness, amputations; inspection and palpation of spine for kyphosis, lordosis, scoliosis, musculature, range of motion, muscles for spasm, or tenderness. NRNP-6531 11 Practice Care Adult across Life Mid Term Exam
- Neurological:
- Mental status: level of alertness; orientation to person, time, place, and circumstances; psychiatric mental status or mini–mental state examinations if indicated.
- Cranial nerves: see Table 2-6 for details of the 12 cranial nerves and their functions.
- Motor: strength testing of upper and lower extremity muscle groups proximally and distally graded on a scale of 0 to 5 as shown in Table 2-7.
- Cerebellum: Romberg test, heel to shin, finger to nose, heel-and-toe walking, rapid alternating movements.
- Sensory: sharp/dull discrimination, temperature, stereognosis, graphesthesia, vibration, proprioception.
- Reflexes: brachioradialis, biceps, triceps, quadriceps (knee), and ankle graded on a scale of 0 to 4+ as shown in Table 2-8.
Based on your reading, complete the application exercises that follow.
Cranial Nerve Number, Name, and Major Function
- I Olfactory – Smell
- II Optic – Visual acuity, visual fields, fundi; afferent limb of pupillary response
- III, IV, VI – Oculomotor, trochlear, abducens – Efferent limb of pupillary response, eye movements
- V – Trigeminal – Afferent corneal reflex, facial sensation, masseter and temporalis muscle testing by biting down
- VI- Facial- Raise eyebrows, close eyes tight, show teeth, smile or whistle, efferent corneal reflex
- VIII – Acoustic – Hearing
- IX, X – Glossopharyngeal and vagus – Palate moves in midline, gag reflex, speech
- XI – Spinal accessory- Shoulder shrug, push head against resistance
- XII – Hypoglossal – Stick out tongue
Table 2-7 Muscle Strength Grading
Muscle Grading and Meaning
- – No motion or muscular contraction detected
- – Barely detectable motion
- – Active motion with gravity eliminated
- – Active motion against gravity
- – Active motion against some resistance
- – Active motion against full resistance
Grading Reflex and Meaning
0 Absent
1+ Decreased or less than normal
2+ Normal or average
3+ Brisker than usual
4+ Hyperactive with clonus
Laboratory and Diagnostic Studies
Following documentation of the H&P, document the results of any studies, such as laboratory tests, radiographs, or other imaging studies. All results should be specifically recorded.
For instance, rather than documenting, “the complete blood count (CBC) is normal,” document the value for each part of the CBC.
This is done for several reasons. First, it presents the actual values and allows readers of the H&P to formulate their own conclusions regarding the meaning of the values.
Second, it documents the baseline values that the patient has as a reference point. Third, it saves time for other readers to have the values listed rather than having to look them up.
Problem List, Assessment, and Differential Diagnosis
Once you have documented all the elements of the H&P and results of diagnostic studies, you can evaluate all the information to identify the patient’s problems.
Use a numbered list that includes the date of onset and whether a particular problem is active or inactive. List the most severe problems first. After the initial list is generated, new problems are listed chronologically.
Make an assessment of each current problem. This entails a brief evaluation of the problem with differential diagnosis.
This is a very important component of the comprehensive H&P because it demonstrates your judgment and documents the medical decision-making that you considered regarding each problem.
Plan of Care
Document any additional studies or workup needed, referrals or consultations needed, pharmacological management, nonpharmacological or other management, patient education, and disposition such as “return to clinic” or “admit to the hospital.”
There are different ways that you can document the assessment and plan. Sometimes you will see assessment and plan documented as numbered or bulleted lists under separate headings, or you may see them together.
Example 2.1 demonstrates the difference in these approaches. Either is acceptable and which is used depends largely on health-care provider preference and whether documentation is paper-based or EMR-based.
EXAMPLE 2.1
Assessment:
- Cough: nonproductive and no signs or symptoms of infectious process. Recently started an angiotensin-converting enzyme (ACE) inhibitor, so may be side effect of medication.
- Diabetes, not well controlled: review of home glucose monitoring logs shows fasting range of 150 to 180.
- New onset left leg swelling: no trauma, no erythema. Pulses are present. Concern for deep vein thrombosis (DVT).
- Plan:
- Stop ACE inhibitor. Will switch to losartan 50 mg once daily. NRNP-6531 11 Practice Care Adult across Life Mid Term Exam
- Check HgbA1C; continue metformin, add glipizide 5 mg twice daily. Continue home glucose monitoring.
- Left leg Doppler flow study.
Return to clinic in 2 weeks.
Assessment/Plan:
- Cough: nonproductive and no signs or symptoms of infectious process. Recently started an ACE inhibitor, so may be side effect of medication. Stop ACE inhibitor. Will switch to losartan 50 mg once daily.
- Diabetes, not well controlled: review of home glucose monitoring logs shows fasting range of 150 to 180. Check HgbA1C; continue metformin, add glipizide 5 mg twice daily. Continue home glucose monitoring.
- New onset left leg swelling: no trauma, no erythema. Pulses are present. Concern for DVT; left leg Doppler flow study.
Return to clinic in 2 weeks.
Sample Comprehensive History and Physical Examination
A sample comprehensive H&P for Mr. William Jensen is shown in Figure 2-2. Mr. Jensen is a new patient to the practice of Dr. Vernon Scott, and you will follow his medical course through the documentation of his encounters with a surgeon, his admission to the hospital, surgery, hospital course, and discharge.
In addition to documentation related to Mr. Jensen, you will have the opportunity to evaluate other documentation.
Summary
The comprehensive history and physical examination (H&P) is one of the most important documents in the patient’s entire medical record.
The H&P will vary somewhat in content at different ages and stages of life and among different medical disciplines as discussed in other chapters; however, the structure of the H&P is typically the same.
Typically, you will complete the comprehensive H&P at an initial patient visit in the ambulatory setting, and documentation of subsequent visits will not be as detailed.
The goal of the H&P is to elicit detailed information about the patient’s medical history to identify risk factors, guide decisions for health maintenance, and to identify and treat conditions that will impact the patient’s health and quality of life.
Completing the worksheets that follow will help reinforce the material presented in this chapter. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation.
Using subheadings within the PMH, as shown in Table 2-3, makes it easier to locate information and identify the change from one topic to another.
Table 2-3 Subheadings Used for Past Medical History
Past Medical History
Medical
Surgical/hospitalizations
Medications
Allergies
Health maintenance/immunizations
if the patient has multiple medical problems, it may be helpful to document them as an enumerated list rather than in paragraph format. If the patient has had any surgery or hospitalizations for major trauma or other reasons, be sure to include the type of operation and date of the surgery; if known, you can include the name of the doctor who performed the surgery. NRNP-6531 11 Practice Care Adult across Life Mid Term Exam
You should document a medication list as part of the PMH. This includes both prescription medications and over-the-counter products, such as herbal supplements, vitamins, minerals, and dietary supplements.
Be sure to include the name of the medication, the dose, how frequently it is taken, and ideally, why the patient takes the medication. Review the list of medications with the patient at every visit to ensure accuracy.
It is extremely important to document any drug allergies the patient has. You may document food allergies in this section also.
You should document the specific reaction the patient experiences when the food or drug is ingested. In most settings, there will be a specific way to indicate a drug allergy, such as a special sticker affixed to the front of the patient’s chart, so that it is not overlooked.
In an electronic medical record (EMR), the text may be a different color or there may be a special tab or menu bar to highlight any allergies.
It is critically important to inquire specifically about and document an allergy to latex. A patient with a latex allergy will need special equipment.
You should document environmental allergies, such as an allergy to cats that results in allergic rhinitis, in the PMH. If the patient is treated regularly for allergy-related conditions, document these conditions under the heading of Medical Conditions rather than Allergies.
The health maintenance and immunization section of the PMH will vary according to the patient’s age and gender. Chapters 5, 6, and 7 discuss documentation of health maintenance activities and immunizations in the pediatric, adult, and older adult patient, respectively.
Family History
Typically, you should document the medical history of first-degree relatives, that is, the family history (FH) for parents, grandparents, siblings, and children.
Remember that a spouse’s medical history is not considered part of the patient’s FH, although it may be applicable in situations in which a couple presents because of infertility or genetic counseling.
Document the age and status (living, deceased, health status) of the first-degree relatives. If those relatives are deceased, include the age at time of death and cause of death.
If the relatives are still living, document their current age and medical conditions, paying particular attention to those conditions that have a familial tendency such as cardiovascular disease, diabetes, and certain cancers, osteoporosis, and sleep apnea.
Also determine whether any first-degree relatives have or had the condition with which the patient is presenting. In addition to medical conditions, inquire about any substance abuse, addictions, depression, or other mental health conditions of family members.
Social History
One of the main goals of documenting the social history (SH) of the patient is to identify factors outside of past or current medical conditions that may influence the patient’s overall health or behaviors that create risk factors for specific conditions.
These risk factors include use of tobacco, alcohol, and drugs. If these risk factors are present, document quantity of use and how long the use has occurred. Smoking history should include number of packs per day and the number of years the patient has smoked.
If the patient formerly smoked or used smokeless tobacco, you still should document the details of the tobacco use with the addition of how long it has been since the patient quit. Avoid ambiguous terms such as social drinker that do not assist you or other readers in determining whether there is a risk factor associated with substance use.
Typically, the use of illegal substances is documented as drug use, but also you should determine whether the patient is taking substances prescribed for someone else or misusing prescription medication. If a risk factor is identified, be sure to include it in the problem list and assessment and plan.
Age-specific SH is discussed in other chapters. Information about the patient’s sexual orientation, gender identification, marital status, and number of children is included.
Documentation of the patient’s past and current employment may help identify potential occupational hazards. Include any military service and where stationed (stateside or overseas) as well as any possible exposures.
If the patient has lived or traveled abroad, document locations and potential exposures, if any. It is important to document the patient’s educational level and ability to read and write.
If the patient speaks more than one language, you should document which language the patient prefers.
Religion and religious and cultural beliefs may have an impact on a patient’s overall health. It can be difficult to determine the difference between a religious belief and a cultural belief, although typically it is not necessary to do so.
Specific documentation of the religious and cultural history includes beliefs related to health and illness, family, symbols, nutrition, special events, spirituality, and taboos. Table 2-4 shows questions that you can ask as part of the religious and cultural history.
Table 2-4Questions to Ask for Cultural and Religious History
Communication
Is a translator needed?
What is your primary oral language?
What is your primary written language?
Beliefs Affecting Health and Illness
What do you think caused your illness or condition?
How does it affect your life?
Have you seen anyone else about this problem?
If yes, who?
Have you used any home remedies for your problem?
If yes, what?
Are you willing to take prescription medications?
Are you willing to use alternative therapies, such as herbal medicine? NRNP-6531 11 Practice Care Adult across Life Mid Term Exam
Family
Definition of family
Roles within family
Who has authority for decision-making related to your health care?
Symbols
Special clothing
Ritualistic and religious articles
Nutrition
Specific food rituals
Specific food avoidances
Major foods
Preparation practices
Special Events
Prenatal care
Death and burial rituals
Beliefs of afterlife
Willing to accept blood transfusions?
Willing to accept organ transplantation?
Organ, blood, or tissue donor?
Spirituality
Dominant religion
Active participant?
Prayer and meditation
Special activities
Relationship between spiritual beliefs and health practices
Taboos
Describe any taboos that would affect health care
Document nutritional information in terms of type of diet the patient follows, caffeine intake, and food allergies or avoidances. If there are questions or concerns about a patient’s diet, it may be helpful to record a “typical day” or “last 24 hours” of food intake.
Sedentary lifestyle is a risk factor for certain diseases, so document whether the patient exercises. If the patient exercises, include the type, frequency, and duration of exercise.
One basic consideration of a patient’s ability to access health care is whether the patient has health-care insurance or some other form of payment, such as Social Security or workers’ compensation.
Although financial records generally should be kept separate from the medical records, you should document whether the patient is insured or uninsured. If uninsured, information about income or ability to self-pay becomes essential.
The provision or lack of insurance will guide many health-care choices, especially related to prescribing medications. Using generic instead of brand-name medications will result in cost savings for the patient and is often medically neutral, meaning the patient should get the same benefit from generic as from brand-name medications.
MEDICOLEGAL ALERT!
Documenting that you have counseled the patient on the risks of negative health habits and the management of chronic disease is an important part of the management of medicolegal risk. Providers have been sued for not providing patient education and counseling.
One such case involved a 33-year-old woman who was obese and hypertensive and smoked. She had frequent visits to the clinic for various complaints.
Routine screening tests revealed marked hypercholesterolemia and an abnormal ratio of high-density lipoprotein (HDL) to low-density lipoprotein (LDL). The health-care provider never counseled the patient regarding her risk for coronary artery disease.
Several years later, the patient presented to an emergency room with crushing chest pain that radiated to her arms and neck. The diagnosis of myocardial infarction was confirmed, but by the time the diagnosis was made, the window of opportunity for thrombolytic therapy had closed.
The patient sued the clinic and the health-care provider for malpractice. The health-care provider was found negligent for not educating and counseling the patient about her risk factors for developing heart disease.
Review of Systems (SUBJECTIVE)
The review of systems (ROS) is an inventory of specific body systems designed to document any symptoms the patient may be experiencing or has experienced.
Typically, you should document both positive symptoms (those the patient has experienced) and negative symptoms (those the patient denies having experienced). A positive response from a patient about any symptom should prompt you to explore all elements of that symptom just as you would for the HPI (location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms).
Rather than asking whether the patient has ever experienced any of the symptoms listed, it is appropriate to limit the review to a specific time frame.
That time frame might change depending on the patient’s CC and HPI; if you are seeing a patient for the first time, it is usually sufficient to ask about the past year. If the patient has been seen before, ask about the time frame since the previous visit.
Consistent with the 1995 and 1997 CMS guidelines, 14 systems are identified, and specific symptoms that should be explored in each system are included here. How many symptoms are explored within each system is up to you as indicated by the patient’s presenting complaint.
Constitutional: these symptoms do not fit specifically with one system but often affect the general well-being or overall status of a patient. Specific symptoms include weight loss, weight gain, fatigue, weakness, fever, chills, and night sweats.
Eyes: change in vision, date of last visual examination, glasses or contact lenses, history of eye surgery, eye pain, photophobia, diplopia, spots or floaters, discharge, excessive tearing, itching, cataracts, or glaucoma.
Ears, nose, and mouth/throat (ENT):
Ears: change in or loss of hearing, date of last auditory evaluation, hearing aids, history of ear surgery, ear pain, tinnitus, drainage from the ear, history of ear infections.
Nose: changes in or loss of sense of smell, epistaxis, obstruction, polyps, rhinorrhea, itching, sneezing, sinus problems.
Mouth/throat: date of last dental examination, ulcerations or other lesions of tongue or mucosa, bleeding gums, gingivitis, dentures, or any dental appliances.
Cardiovascular (CV): chest pain, orthopnea, murmurs, palpitations, arrhythmias, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema, claudication, date of last electrocardiogram or other cardiovascular studies.
Respiratory: dyspnea, cough, amount and color of sputum, hemoptysis, history of pneumonia, date of last chest radiograph, date and result of last tuberculosis testing.
Gastrointestinal (GI): abdominal pain; dysphagia; heartburn; nausea; vomiting; usual bowel habits and any change in bowel habits; use of aids such as fiber, laxatives, or stool softeners; melena; hematochezia; hematemesis; hemorrhoids; jaundice.
Genitourinary (GU): frequency, urgency, dysuria, hematuria, polyuria, incontinence, sexual orientation, number of partners, history of sexually transmitted infections, infertility.
Males: hesitancy, change in urine stream, nocturia, penile discharge, erectile dysfunction, date of last testicular examination, date of last prostate examination, date and result of last prostate-specific antigen (PSA) test.
Females: GU symptoms as described previously and gynecological symptoms; age at menarche; gravida, para, abortions; frequency, duration, and flow of menstrual periods; date of last menstrual period; dysmenorrhea; type of contraception used; ability to achieve orgasm; dyspareunia; vaginal dryness, menopause; breast lesions, date and type of last breast imaging; date and result of last Papanicolaou smear, date of last pelvic examination.
Musculoskeletal (MSK): arthralgias, arthritis, gout, joint swelling, trauma, limitations in range of motion (ROM), back pain. (Note that numbness, tingling, and weakness are typically not included in musculoskeletal but in neurological system.)
Integumentary: rashes, pruritus, bruising, dryness, skin cancer or other lesions.
Neurological: syncope, seizures, numbness, tingling, weakness, gait disturbances, coordination problems, altered sensation, alteration in memory, difficulty concentrating, headaches, head trauma, or brain injury. (Headache, head trauma, or brain injury may also be listed under head, as part of Head, Eyes, Ears, Nose, Mouth/Throat, or HEENT.)
Psychiatric: emotional disturbances, sleep disturbances, substance abuse disorders, hallucinations, illusions, delusions, affective or personality disorders, nervousness or irritability, suicidal ideation or past suicide attempts.
Endocrine: polyuria, polydipsia, polyphagia, temperature intolerance, hormone therapy, changes in hair or skin texture.
Hematologic/lymphatic: easy bruising, bleeding tendency, anemia, blood transfusions, thromboembolic disorders, lymphadenopathy.
Allergic/immunologic: allergic rhinitis, asthma, atopy, food allergies, immunotherapy, frequent or chronic infections, HIV status; if HIV positive, date and result of last CD4 count.
You may use standard forms or templates for gathering much of the history information, and this is certainly an acceptable, time-saving practice.
However, you have an obligation to review and verify the information that the patient provides. Staff members may use the forms to enter information into an EMR. The original paper forms should be scanned into the EMR.
Physical Examination (OBJECTIVE)
The rationale for physical examination rests on a basic assumption that there is such a thing as normality of bodily structure and function corresponding to a state of health and that departures from this norm consistently result from or correlate with specific abnormal states or disease.
It is helpful to think about a “range of normal” when it comes to physical examination findings, rather than a single “normal” for every part of the examination.
The physical examination may confirm or refute a diagnosis suspected from the history, and by adding this information to the database, you will be able to construct a more accurate problem list.
Like the history, the physical examination is structured to record both positive and negative findings in detail.
Generally, the examination will proceed in a head-to-toe fashion. In some instances, it may be necessary to deviate from this order, such as performing an invasive component at the end of the examination or examining an area of pain last.
Regardless of the order in which the examination is performed, documentation of the physical examination should follow the order that follows and in Table 2-5.
Consult other textbooks for instruction on how to perform the physical examination and for a discussion on the importance of any findings; here the emphasis is on the documentation of a comprehensive physical examination.
General assessment (OBJECTIVE)
Vital signs: temperature, pulse, respiration, blood pressure, height, weight, body mass index (BMI)
Skin
HEENT
Neck
Respiratory
Cardiovascular
Abdomen
Genitourinary or gynecological
Musculoskeletal
Neurological
General: age, race, gender, general appearance. Documentation of general appearance could include alertness, orientation, mood, affect, gait, how a patient sits on the examination table or chair, grooming, and the patient’s reliability to provide an adequate history. Document whether the patient is in any distress or whether the patient appears markedly older or younger than the stated age.
OBJECTIVE DATA
Vital signs: temperature, blood pressure, pulse, respiratory rate, height, weight, and body mass index (BMI).
Skin: presence and description of any lesions, scars, tattoos, moles, texture, turgor, temperature; hair texture, distribution pattern; nail texture, nail base angle, ridging, pitting.
HEENT:
Head (including face): size and contour of head, symmetry of facial features, characteristic facies, tenderness, or bruits of temporal arteries.
Eyes: conjunctivae; sclera; lids; pupil size, shape, and reactivity; extraocular movement (EOM); nystagmus; visual acuity. Ophthalmoscopic findings of cornea, lens, retina, red reflex, optic disc color and size, cupping, spontaneous venous pulsations, hemorrhages, exudates, nicking, arteriovenous crossings.
Ears: integrity, color, landmarks, and mobility of the tympanic membranes; tenderness, discharge, external canal, tenderness of auricles, nodules.
Nose: symmetry, alignment of septum, nasal patency, appearance of turbinates, presence of discharge, polyps, palpation of frontal and maxillary sinuses.
Mouth/throat: lips, teeth, gums, tongue, buccal mucosa, tonsillar size, exudate, erythema.
Neck: ROM, cervical and clavicular lymph nodes, thyroid examination, position, and mobility of the trachea.
Respiratory: effort of breathing, breath sounds, adventitious sounds, chest wall expansion, symmetry of breathing, diaphragmatic excursion.
Cardiovascular: heart sounds, murmurs or extra sounds, rhythm, point of maximal impulse, peripheral edema, central and peripheral pulses, varicosities, venous hums, bruits.
Breast: symmetry, inspection for dimpling of skin, nipple discharge, palpation for tenderness, cyst or masses, axillary nodes, gynecomastia in males.
Abdomen: shape (flat, scaphoid, distended, obese), bowel sounds, masses, organomegaly, tenderness, inguinal nodes.
Male genitalia or gynecological (breast examination sometimes documented here).
Male genitalia: hair distribution, nits, testes, scrotum, penis, circumcised or uncircumcised, varicocele, masses, tenderness.
Gynecological: External inspection of the perineum for lesions, nits, hair distribution, areas of swelling or tenderness, labia and labial folds, Skenes and Bartholin glands, vaginal introitus; noting any discharge or cystocele if present. Internal—inspect vaginal walls and cervix for color, discharge, lesions, bleeding, atrophy; inspect cervical os for size and shape; bimanual examination for size, shape, consistency and mobility of the cervix; cervical motion tenderness, uterine or ovarian enlargement, masses, tenderness, adnexal masses or tenderness.
Rectal: hemorrhoids, fissures, sphincter tone, masses, rectocele; if stool is present, color and consistency of stool, test stool for occult blood; prostate examination for males, noting size, uniformity, nodules, tenderness.
Musculoskeletal: symmetry of upper and lower extremities, ROM of joints, joint swelling, redness or tenderness, amputations; inspection and palpation of spine for kyphosis, lordosis, scoliosis, musculature, range of motion, muscles for spasm, or tenderness.
Neurological:
Mental status: level of alertness; orientation to person, time, place, and circumstances; psychiatric mental status or mini–mental state examinations if indicated.
Cranial nerves: see Table 2-6 for details of the 12 cranial nerves and their functions.
Motor: strength testing of upper and lower extremity muscle groups proximally and distally graded on a scale of 0 to 5 as shown in Table 2-7.
Cerebellum: Romberg test, heel to shin, finger to nose, heel-and-toe walking, rapid alternating movements.
Sensory: sharp/dull discrimination, temperature, stereognosis, graphesthesia, vibration, proprioception.
Reflexes: brachioradialis, biceps, triceps, quadriceps (knee), and ankle graded on a scale of 0 to 4+ as shown in Table 2-8.
Based on your reading, complete the application exercises that follow.
Cranial Nerve Number, Name, and Major Function
I Olfactory – Smell
II Optic – Visual acuity, visual fields, fundi; afferent limb of pupillary response
III, IV, VI – Oculomotor, trochlear, abducens – Efferent limb of pupillary response, eye movements
V – Trigeminal – Afferent corneal reflex, facial sensation, masseter and temporalis muscle testing by biting down
VI- Facial- Raise eyebrows, close eyes tight, show teeth, smile or whistle, efferent corneal reflex
VIII – Acoustic – Hearing
IX, X – Glossopharyngeal and vagus – Palate moves in midline, gag reflex, speech
XI – Spinal accessory- Shoulder shrug, push head against resistance
XII – Hypoglossal – Stick out tongue
Table 2-7 Muscle Strength Grading
Muscle Grading and Meaning
– No motion or muscular contraction detected
– Barely detectable motion
– Active motion with gravity eliminated
– Active motion against gravity
– Active motion against some resistance
– Active motion against full resistance
Grading Reflex and Meaning
0 Absent
1+ Decreased or less than normal
2+ Normal or average
3+ Brisker than usual
4+ Hyperactive with clonus
Laboratory and Diagnostic Studies
Following documentation of the H&P, document the results of any studies, such as laboratory tests, radiographs, or other imaging studies. All results should be specifically recorded.
For instance, rather than documenting, “the complete blood count (CBC) is normal,” document the value for each part of the CBC.
This is done for several reasons. First, it presents the actual values and allows readers of the H&P to formulate their own conclusions regarding the meaning of the values.
Second, it documents the baseline values that the patient has as a reference point. Third, it saves time for other readers to have the values listed rather than having to look them up.
Problem List, Assessment, and Differential Diagnosis
Once you have documented all the elements of the H&P and results of diagnostic studies, you can evaluate all the information to identify the patient’s problems.
Use a numbered list that includes the date of onset and whether a particular problem is active or inactive. List the most severe problems first. After the initial list is generated, new problems are listed chronologically.
Make an assessment of each current problem. This entails a brief evaluation of the problem with differential diagnosis.
This is a very important component of the comprehensive H&P because it demonstrates your judgment and documents the medical decision-making that you considered regarding each problem.
Plan of Care
Document any additional studies or workup needed, referrals or consultations needed, pharmacological management, nonpharmacological or other management, patient education, and disposition such as “return to clinic” or “admit to the hospital.”
There are different ways that you can document the assessment and plan. Sometimes you will see assessment and plan documented as numbered or bulleted lists under separate headings, or you may see them together.
Example 2.1 demonstrates the difference in these approaches. Either is acceptable and which is used depends largely on health-care provider preference and whether documentation is paper-based or EMR-based.
EXAMPLE 2.1
Assessment:
Cough: nonproductive and no signs or symptoms of infectious process. Recently started an angiotensin-converting enzyme (ACE) inhibitor, so may be side effect of medication.
Diabetes, not well controlled: review of home glucose monitoring logs shows fasting range of 150 to 180.
New onset left leg swelling: no trauma, no erythema. Pulses are present. Concern for deep vein thrombosis (DVT).
Plan:
Stop ACE inhibitor. Will switch to losartan 50 mg once daily.
Check HgbA1C; continue metformin, add glipizide 5 mg twice daily. Continue home glucose monitoring.
Left leg Doppler flow study.
Return to clinic in 2 weeks.
Assessment/Plan:
Cough: nonproductive and no signs or symptoms of infectious process. Recently started an ACE inhibitor, so may be side effect of medication. Stop ACE inhibitor. Will switch to losartan 50 mg once daily.
Diabetes, not well controlled: review of home glucose monitoring logs shows fasting range of 150 to 180. Check HgbA1C; continue metformin, add glipizide 5 mg twice daily. Continue home glucose monitoring.
New onset left leg swelling: no trauma, no erythema. Pulses are present. Concern for DVT; left leg Doppler flow study. NRNP-6531 11 Practice Care Adult across Life Mid Term Exam
Return to clinic in 2 weeks.
Sample Comprehensive History and Physical Examination
A sample comprehensive H&P for Mr. William Jensen is shown in Figure 2-2. Mr. Jensen is a new patient to the practice of Dr. Vernon Scott, and you will follow his medical course through the documentation of his encounters with a surgeon, his admission to the hospital, surgery, hospital course, and discharge.
In addition to documentation related to Mr. Jensen, you will have the opportunity to evaluate other documentation.
Summary
The comprehensive history and physical examination (H&P) is one of the most important documents in the patient’s entire medical record.
The H&P will vary somewhat in content at different ages and stages of life and among different medical disciplines as discussed in other chapters; however, the structure of the H&P is typically the same.
Typically, you will complete the comprehensive H&P at an initial patient visit in the ambulatory setting, and documentation of subsequent visits will not be as detailed.
The goal of the H&P is to elicit detailed information about the patient’s medical history to identify risk factors, guide decisions for health maintenance, and to identify and treat conditions that will impact the patient’s health and quality of life.
Completing the worksheets that follow will help reinforce the material presented in this chapter. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation. NRNP-6531 11 Practice Care Adult across Life Mid Term Exam
