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20 Cards in this Set
- Front
- Back
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Mnemonic: OLDCARTS
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Onset, Location, Duration, Character, Aggravating/Assoc factors, Relieving factors, Temporal factors, Severity of symptoms
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Mnemonic: SOAP
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Subjective
Objective Assessment Plan |
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Pedigree symbols
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Male: Square (Unaffected)
Female: Circle (Unaffected) Gender Unknown: Diamond Deceased: Line slash through symbol Affected: Dark shaded in X-linked Carrier: Dot in symbol (female) X-linked Carrier: Light shaded in (male or female) X-linked Figure 26-3. |
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Avoid vague non-descriptive terms
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Like "Normal"
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Treat the chart as a legal document
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Draw a line through mistakes
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Privacy of patient records becoming more difficult
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Due to computerized data
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Document missing teeth/cavities by tooth number
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T=36 in adult (includes 4 wisdom teeth)
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Use only universally accepted abbreviations
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Ex: Unit - not U
Ex: Daily - Not QD |
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Use stick figures, etc in the chart
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for noting location of lesions, nerve pain, etc.
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OK to record limited information during the exam (notes)
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Then expand shortly after
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Avoid inferring or concluding
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Document what patient says and you observe
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When do you use incremental grading?
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For deep tendon reflexes
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Use numbers on a clock-face for round objects
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Ex: Tympanic membrane
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Use Tanner staging for:
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Assessment of sexual maturity and development in children and adolescents
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Plan is divided into 3 sections:
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Therapeutics, Diagnostics, and Education
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The infant health history also includes:
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Prenatal information
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If data is omitted...
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State: data omitted
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POMR
6 components of Problem-Oriented Medical Record |
Comprehensive health history (Present, Past, Family, and Personal/Social History)
Complete physical exam Problem list Assessment and plan Baseline and problem-directed (labs/rads) Progress notes |
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SOAP
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Subjective
Objective Assessment Plan |
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Woohoo!! Ya made it through chap 26
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w/o falling asleep
Time for a Rita!! Who's with me? |
