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8 Cards in this Set
- Front
- Back
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When does the case history occur in the exam?
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You should start with the case history but it continues throughout the exam. (It never ends.)
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What are the 5 parts of the case history format that we learned in class?
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CC, HPI, PMH and POH, FMH and FOH, P/S, ROS
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What are the 7 aspects of the HPI that are investigated.
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location, quality, severity, context, duration, modifying factors, associated signs and symptoms
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In the P/S section what is important to ask about.
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DiSH
What do you Do? When and where do you See? What Hazards might you come into contact with. |
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What are the 14 things that you ask about in the ROS section?
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Eyes, ENT, skin, H/N, M/S, pulm, CV, GI, U/G, endo, heme, Neuro, Phych, anx/dep
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to what 3 things does the clinician decide if the patient is oriented at the end of the case history?
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-time
-place -person |
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To bill for a comprehensive eye exam you must have
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1CC
4HPI 10ROS MAO 2Patient family/social history |
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What does SOAP stand for?
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S=subjective
O=objective A=assesment P=plan |
