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:Providing Structure to Data History History of present illness: progressive weight gain; tight shoes, then pants fit tight; exertional dyspnea Allergies: aspirin (rash); hypertension medication (slowed me down) Patient medical history: hypertension Social: quit smoking Surgical history: tonsillectomy Physical General: pale, healthy M Vital signs: BP: 225/140; pulse 120; respirations 12 Head and neck negative Lungs clear Heart: S4 heard, no murmur Abdomen nontender ; no hepatosplenomegaly Extremities: 2+ pitting to mid-shin 11
Slide notes:This slide gives structure to the data by placing selected items in the conventional order of the history and physical. This is the first step in processing the information to make sense of it. The next step in analyzing the findings is to look for patterns and meaning in this data. Clinical information systems and EHRs ideally should facilitate the data collection process, resulting in the display of patient data in a structured format. 11