Medical Record

Dr. Jing Xiao

No greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering, [the physician] needs technical skill, scientific knowledge, and human understanding. . . . Tact, sympathy, and understanding are expected of the physician, for the patient is no mere collection of symptoms, signs, disordered functions, damaged organs, and disturbed emotions. [The patient] is human, fearful, and hopeful, seeking relief, help, and reassurance.

–Harrison's Principles of Internal Medicine, 1950

Content

The importance of Medical record The Format and content of Medical Re

cord Commonly used medical documentati

on

Why is Medical Record Important

Medical Purpose Legal Purpose Research Purpose Reimbursement

The primary purposes of enabling a physician to document his or her care in the medical record are to serve the memory of the caregiver and communicate these data to other physicians caring for the patient.

Use of the record for legal and billing purposes are secondary and should not distract or interfere with good patient care.

Sample Identification Informant Chief Complaints (CC) History of Present Illness (HPI) Past Medical and Surgical History (PH) Family History (FH) Social history (SH) Review of Systems (ROS) Medications Allergies and Medication Intolerances

Taking (or receiving) histories is what most of us spend most of our professional life doing, and it is worth doing well. A good history is the biggest step towards correct diagnosis. History-taking, examination, and treatment begin the moment one reaches the bedside.

Oxford handbook of clinical medicine,8th

History Taking Asking patients to describe, in their own

words, the reason for seeking medical care. Be encouraged to select the single or two

most important concerns they have. Be reassured that other concerns will not be

ignored but wants to understand what is most important

Describing a symptom or sign rather than a diagnosis.

Description of the patient

 Age gender ethnic background occupation

Chief reason for seeking care   

State the purpose of the evaluation (usually in the patient's words)

precise, no more than 20characters

History of the Present Illness

Open-ended questions in their own words.

Followed by a series of specific questions

Limit open-ended discussion and move to the most important features when the patient is acutely ill

History consideration Description of onset and chronology Location of symptoms Character (quality) of

symptoms Intensity Precipitating, aggravating, and relieving

factors Inquiry into whether the problem or similar

problems occurred before and, if so, whether a diagnosis was established at that time

SOCRATES Site Onset (gradual, sudden) Character Radiation Association (eg nausea, sweating) Timing of pain/duration Exacerbating and alleviating factors Severity (eg scale of 1-10, compare with chil

dbirth/worst ever previous pain)

Telling a story In chronological fashion, determine th

e evolution of the indication for the visit and then each major symptom.

Be careful to avoid “premature closure,”

a diagnosis is assumed before all the information is collected

Finally, it is often helpful to ask patients to express what they believe is the cause of the problem or what concerns them the most. This approach often uncovers other pertinent factors and helps establish that the physician is trying to meet the patient's needs.

Past Medical and Surgical History

An astute clinician should not rely on patients to divulge all their prior problems, however, because they may forget, may assume that previous events are unrelated to their current problem, or simply may not want to discuss past events.

An open-ended statement such as “Tell me about other medical illnesses you have had that we did not discuss” and “Tell me about any operations you have had” prompts the patient to consider other items.

During the physical examination, the physician should ask the patient about unexplained surgical or traumatic scars.

Family history

  History of any diseases in first-degree relatives and a listing of family members with any conditions that could be risk factors for the patient (e.g., cardiovascular disease at a young age, malignancy, known genetic disorders, longevity)

The social history can also provide important insights into the types of diseases that should be considered.

Data that may influence risk factors for disease should be gathered, including a nonjudgmental assessment of substance abuse. The tobacco history should include the use of snuff, chewing tobacco, and cigar and cigarette smoking.

Alcohol use should be determined quantitatively and by the effect that it has had on the patient's life.

Social history

The sexual history should include current sexual activity, including the number of partners and past history.

The employment history should include the current and past employment history, military experience, and any significant hobbies.

Information should be elicited from military veterans regarding their combat history, years of service, and areas of deployment.

The physician should also obtain information on socioeconomic status, insurance, the ability to afford or obtain medications, and past or current barriers to health care because of their impact on care of the patient

Marital status and the living situation (i.e., whom the patient lives with, significant stressors for that patient) are important as risk factors for disease and to determine how best to care for the patient.

A patient's culture and values should be known, including any prior advance directives or desire to overrule them

The physician should explicitly elicit and record information regarding the next of kin; surrogate decision makers; emergency contacts; social support systems; and financial, emotional, and physical support available to the patient.

Review of Systems The review of systems, which is the structur

al assessment of each of the major organ systems, elicits symptoms or signs not covered, or overlooked, in the history of the present illness. In practice, the review of systems may be accomplished by direct questioning or by having the patient fill out a previsit questionnaire that constrains the answers to a specific time frame.

When directly obtained, the best approach is not to use open-ended questions but rather to proceed efficiently and effectively by asking direct questions. The physician may ask the patient, “Has there been any recent change in your vision” or “Have you recently had shortness of breath, wheezing, or coughing?”

One estimate is that the review of systems yields a new important diagnosis about 10% of the time. Nevertheless, the review of systems is an efficient mechanism for detecting issues and for obtaining a complete understanding of the patient's overall status.

Medications A list of current medications should include

prescriptions, over-the-counter medications, vitamins, and herbal preparations.

When a patient is uncertain about the names of medications, the patient or family member should be asked to bring all medication bottles to the next visit.

Patients may not consider topical medications (e.g., skin preparations or eye drops) as important, so they may need prompting.

Allergies and Medication Intolerances Information about allergies is particularly importa

nt to collect but also challenging. Patients may attribute adverse reactions or intolerances to allergies, but many supposed allergic reactions are not truly drug allergies. Less than 20% of patients who claim a penicillin allergy are allergic on skin testing.

Eliciting the patient's actual response to medications facilitates a determination of whether the response was a true allergic reaction.

Distinguish allergies from adverse reactions or intolerance to medication (e.g., dyspepsia from nonsteroidal anti-inflammatory agents)

Physical Examination (PE) Vital Signs General appearance Head, eyes, ears, nose, and throat (HEENT) Neck and spine Chest: breasts Chest: chest wall and lungs Chest: heart, major arteries, and neck

veins Abdomen

Genitourinary exam, including inguinal hernias

Rectal exam Extremities Lymph nodes Neurologic exam, including the

mental status exam inaction skin

System PE

Physical Examination-general 1.Vital Signs

Blood pressure ： Pulse rate ： Temperature ： Respiratory

rate ： Height ： Weight ： General appearance ：

2.Mental status

3.Neck.shape ， trachea ， thyroid ，blood vessels.

4.Breasts ： symmetry ， nipples ，masses ， tenderness.

5.Chest ： skin ， thorax （ shape ， symmetry ） ⑴Lungs ： fremitus, resonance, breath sounds ⑵Heart ：

Inspection ： jugular venous pulsations ， point PMI

Palpation ： locate PMI ， thrill Percussion ： heart size Auscultation ： Rate ， rhythm.Heart sounds.

murmurs.

6.Abdomen ： contour ， skin ，hair and scars. ⑴intestinal activity ⑵rigidity and tenderness. ⑶Percussion for dullness. ⑷organs and masses ⑸shifting dullness ⑹collateral circulation

Back

Curvatures ， symmetry ， mobility Tenderness over spine Pelvis Kidneys (costovertebral angle tender

ness ）

Rectum ： Genitals ： Pelvis ： Extremities ： Granial Nerves Gait 、 Cerebellum 、 Sensory Associative 、

Functions 、 Motor

Laboratory and Imaging Studies

Record the results of the initial laboratory finding which you have used to assist in the development of your differential diagnosis.

Basic Laboratory Data

1.Hematology ： WBC, RBC, Hb, Hematocrit, platelet

2.Urinalysis 3.Stool occult blood 4.Sputum Smear 5.Electrocardiogram 6.Chest X-ray 7.B-ultra sound

Case Summary Brief but essential summary of

⑴history ⑵physical examination ⑶contribution ancillary dataAnalyze the chronology, symptoms, signs, and

laboratory findings of the illness Formulation of Diagnoses. Problems and Plans Define and solve each diagnosis and

problem individually.

Assessment or Problem list

Diagnostic and management problems

Keep the patient’s chief complaint the first problem

Maintain, update and revise

Plan

1 plans for testing your hypothesis or differential diagnosis

2 therapy to be considered or given

3 education for the patient and family

Inpatient progress notes

Made daily and whenever necessary

Should be dated and the time of day recorded

Four subheads (SOAP) S: Subject data (symptoms and changes

in symptoms, their appearance and disappearance, and their response to therapy)

O: Object data (changes in or new physical signs and laboratory findings and response to therapy)

A: Assessments (updates to your problem list and hypotheses)

P: Plans (diagnostic tests, therapeutic interventions and instructions to the patient and nursing staff)

Electronic Medical Records This type of information is invaluable for ongoing efforts

to enhance quality and improve patient safety. Ideally, patient records should be easily transferred across the health care system, providing reliable access to relevant data and historic information.

However, technology limitations and concerns about privacy and cost continue to limit a broad-based utilization of electronic health records in most clinical settings.

In this regard, clinical knowledge and an understanding of the patient's needs, supplemented by quantitative tools, still seem to represent the best approach to decision-making in the practice of medicine.

Q & A