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:Clinical Process: The Myth History Physical Assessment Plan The complete history and physical Discrete Linear Orderly Structured 5
Slide notes:While trying to understand the clinical process of taking care of patients such as this man with leg swelling, one danger is that creating a model can accidentally introduce attributes that are not part of the process itself. These may be artifacts of the model. To further illustrate this point, consider that the clinical process is often described or initially learned as depicted on this slide, beginning with the patients history, followed by the physical examination, then followed by a step in which all the data are gathered to form an assessment, and concluding with the creation of the patients management plan of care. This so-called complete history and physical appears to be a discrete, linear, orderly, and structured process. Although it can be performed this way, observation of clinicians in real life suggests that the process often does not follow this rigid pattern at all. 5