Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Gathering data and analyzing findings
Making a diagnosis
The impact of EHRs and technology on clinical decision-making
Slide content:Select the Important Information The clinic assistant says, Blood pressure 225 over 140 (blue) , as she brings in a man (blue) whose shoes are untied and loosened, with ankles bulging (blue) over the top. He looks healthy (blue) enough, but a little pale (red) . He says hes a little short of breath after walking (red) in from the parking lot, but his lungs sound clear (blue) , and hes only breathing 12 times a minute (blue) . Do you smoke (red) ? you ask. I used toI quit (red) three years ago. He says hes been gaining weight (red) lately, and his clothes are fitting tight (red) . You check his heart, which has an S4 gallop, but no murmur (blue) . You ask about his clothes: first his shoes, later his pants (red) , felt too tight. You check his abdomen, which shows no tenderness, masses, or enlarged organs (blue) . Then he recalls he was on medication for blood pressure (red) a few years ago but stopped taking it because he felt slowed down (red) . You check his pulse, its 120 (blue) , and on his legs you notice 2+ pitting to mid-shin (blue) . Have you ever been sick before? you ask. No, never in all my thirty-nine years, except once when I got a rash from aspirin (red) . Oh yeah, and to have my tonsils (red) out. 10
Slide notes:Knowing this structure, we can return to the story presented earlier, of the man who came to the office with swollen ankles. In this slide, the key elements of the story are highlighted, indicating the symptoms reported by the patient, which are colored red, and the observations of the clinician, colored blue. Having selected these key elements, the next task in the clinical process is to reorganize the information into a conventional format. 10