STRUCTURED HISTORY, DOCUMENTATION AND DECISION SUPPORT TECHNOLOGY

Matthew Catterall

Teaching Aim & Learning Outcomes

Aim To gain a working knowledge of structured history collection from a patient, its documentation and use of decision support technology Learning Outcomes Explore communication strategies Describe and discuss the stages in the medical model of assessment Appreciate methods for documenting an assessment

Practical Use of a Structured History

History & Documentation should demonstrate the following elements

SUBJECTIVE

What you find out from the patient/relatives/carers

What you find out from your examination measurable and repeatable Putting together the information you have gained, what do you think is going on? What are you going to do about it? Prescribe/Advise/Refer

OBJECTIVE

ASSESSMENT / ANALYSIS

PLAN

Health History

A thorough, accurate & systematic review Explores past & present problems Can lead to a diagnosis which can then be confirmed or rejected by an examination of the patient The history gives you subjective data from which to work

Medical History

PC Presenting Complaint HPC History of Presenting Complaint PMH/PSH Previous medical/surgical history DH Drug History SH Social History FH Family History ROS review of systems O/E On Examination (focussed systems exam) Assessment/Analysis Plan

Presenting Complaint
Presenting complaint A short description of the reason for seeking care Based on what the patient tells you

E.g Faint, Left Ankle Injury, Feeling tired, Chest pain

History of the presenting complaint The nature of the problem How and when it started How it has progressed over time Impact on the patient

Work, exercise, social activities

HPC Example

2/7 ago playing football at 1100 Fell inverting left ankle whilst running for ball Able to play on for 1/24 Becoming progessively more painful despite analgesia Today pain ++ with inability to weight bear Unable to drive to work Driven to hospital by wife

Previous Medical/Surgical History

Previous medical history

E.g

Asthma, COPD, IBS

Hysterectomy (2003), CABG (2007)

Previous surgical history (date)

E.g

Current management Effectiveness Prognosis

Drug History

Drug, dose, route, frequency Prescribed medication Over the counter medication Herbal remedies Illicit, street or recreational drugs Allergies/ senstivities/ intolerance

Social History

Occupation/s Alcohol (ETOH) units/week

Men 21 Women 14

Smoking (cigarettes/day) Actvities of Daily Living (ADLs) Any formal/informal care Relatives, family, friends etc Accomodation Mobility aids Hobbies Recent travel

Family History

Current family make up Grandparents, parents, siblings Causes of death where relavant Diagnosed diseases

Review of systems (RoS)

Functional enquiry Tailored to the presenting complaint Record pertinent negatives as well as positives Includes all major systems

Look for evidence of....

Respiratory System (RS) Cough, Sputum, Haemoptysis, Shortness of breath (SOB), Wheeze Cardiovascular (CVS) Chest pain (at rest or on exertion), Palpitations, Shortness of breath, Odemea, Orthopnea Gastrointestinal (GI) Indigestion, Abdominal pain, Nausea, Vomiting, Change in bowel habit, Unintentional weight loss, Appetite, Diarrhoea, PR bleed, Dysphagia

Look for evidence of.... Cont

Genitoruninary (GU) Urgency, Frequency, Polyuria, Dysuria, Haematuria, Nocturia, Menstrual problems (Pregnancy ?) Neurological (NS) Faints, fits & funny turns, Loss of consciousness, Headache, Visual disturbances, Dizziness or vertigo, Tingling, Incontinence, Rash, Photophobia Musculoskeletal (MS) Aches, Pains, Stiffness

Documentation
the patient has been depressed since he started seeing me in 1983 the patient was to have a bowel resection. However he took a job as stockbroker instead

she slipped on the ice and her legs wen separate ways in early December

Documentation
Concise Relevant Legible Legal document & part of patients medical record NOT DOCUMENTED = NOT DONE!! Remember your notes may need to be defended in court

Use ink, write legibly, use abbreviations carefully, dont write humorous comments - record factual information only

Include contextual information Date & Time (24 Hour Clock), Location, Your Details, Patient Information (Name, Age, Gender, Occupation)

On Examination (O/E)

Record an initial impression

Pt sitting in chair, not distressed, responding appropriately. Mother present during examination

Examine appropriate system/s Consider limitations without chaperone During your assessment analyse the following factors Likely explanation for the presentation Is the patient

Comfortable or distressed Well or ill Well nourished/hydrated Exhibiting classical signs (syndromes)

Documenting System Examinations

Respiratory System (RS) Nervous System (NS)

Abdomen (Abdo, GI, GU)

Diagnosis & Treatment Planning

Diagnosis (Dx)

Treatment Plan (Rx)

Final diagnosis Synthesis of history and examination Not always clear Impression often suffices in urgent/emergency care Working diagnosis may be required

Enables early treatment of urgent problems

Differenetial Diagnosis (DDx) Dictates treatment Range of potential diagnoses Ruled in or out by investigations Demonstrates consideration of red flag presentations

Tailored to patient Specific instructions for interventions Advice to patient Discharge instructions Referral Follow up care Safety Net advice

999 if chest pain, GP review if not resolving etc

Decision Support Technology

Example Algorithm

Any questions?

References

Bickley, L. (2003). Bates' guide to physical examination and history taking. Philadelphia: Lippincott, Williams and Wilkins. Douglas, G., Nicol, F. & Robertson, C. (2009). Macleods clinical examination. (12th ed.). Edinburgh: Churchill Livingstone Elsevier. Wardrope, J., Driscoll, P., Laird, C. & Woollard, W. (2008). Community emergency medicine. Edinburgh: Churchill Livingstone Elsevier.

This presentation has been sourced from the above texts however there are many texts which refer to the same information.