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:Structured Data Organization Source identification Chief complaint History of present illness Past history Allergies/adverse reactions Medications/treatments Past medical problems Past surgeries Menstrual/obstetric history Immunization/preventive care Family and social history Review of body systems Physical examination Appearance/vitals/skin Head and neck Lungs/heart Abdomen/genitalia Extremities/back Neurologic Ancillary data, diagnostic test results 9
Slide notes:Medical students learn and memorize a comprehensive history and physical format as a cognitive structure that gives organization and meaning to information that otherwise might be disjointed or difficult to comprehend. Through repetition and practice, this format becomes second nature and provides an efficient scaffolding for thinking and communication. Once the novice has acquired sufficient expertise, it becomes necessary to tailor and individualize the process to the patient and the context. The novice might know the rules, but the expert knows the exceptions. This slide shows a very brief overview of the structure and organization of data in the history and physical. Most textbooks that teach clinical skills contain an example of this arrangement. The organizational scaffolding begins with data that identifies the patient and also the source of the information, which may be the patient, a family member, old records, or another source. This is followed by what is called the chief complaint , or the reason for the hospital admission or office visit. Clinicians are typically encouraged to use the patients own words when recording the chief complaint. Following this is the history of the present illness. This is usually a chronologically ordered narrative, in a paragraph or more, containing the details of the patients current problem as explained to the clinician. Next is a summary of the patients past history. This summary has a substructure that includes specific information about allergies, current medications and treatments, past medical and surgical history, vaccinations and preventive care, and for women, their menstrual and obstetric history. This section is followed by a social history, which includes occupation, habits, and healthy or risky behaviors, and then by a family history, which includes any illnesses that may run in the family, such as cancer, heart disease, and hypertension. The next area of the history and physical contains a complete review of the body systems. A detailed review of each organ and body system may elucidate important symptoms that have not come to light through other means. The history and physical then proceeds to the findings upon physical examination, which also has a highly structured format. Ancillary data such as laboratory test results, x-rays, and other diagnostic test results are included. Once these results are recorded in the history and physical, the data collection phase is complete. Next, the patient assessment and the patients plan of care are addressed by the clinician. It may be worth noting that this order of information is analogous [uh- nal -uh- guh s] to, or somewhat parallels, the structure of scientific papers and scientific argument. A statement of the problem precedes the description of the methods and findings, and these sections precede the interpretation of the findings and the authors conclusions. 9