Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Making a diagnosis
Choosing therapy
Communicating the plan
The impact of EHRs and technology on clinical decision-making
Slide content:Problem List: Building Relationship, Negotiating Plans Diabetes Polyuria, polydipsia, polyphagia Hyperglycemia HTN High BP x 3 EKG shows left ventricular hypertrophy Hyperlipidemia LDL 194 Triglycerides 250 Body Mass Index 34 5
Slide notes:To begin this discussion, consider a patient who has come to see a clinician to establish care. In the course of the visit, a problem list has been generated that includes diabetes causing frequent urination, excessive thirst, an increased appetite, and high blood sugar. The list also includes high blood pressure based on three previously recorded blood pressures that were abnormal and evidence on an electrocardiogram that the heart is being affected. Furthermore, low-density lipoprotein [lip-oh- proh -teen], or LDL [L-D-L], levels are far above the goal at 194, and the triglyceride level is high based on a test result of 250. The patient is also overweight, with a body mass index of 34. As the clinician develops a management plan with the patient for each of these problems, it becomes important to communicate these problems and the evolving plan to others. 5