Medical Process (Introduction to Medical Informatics) (http://www.cpmc.columbia.edu/edu/textbook) LAST REVIEWED: 22 September 1997 goal of health care help people maintain good health through prevention and treatment the structure and use of medical data are based on this goal goal is achievable only through proper structure (reading) purpose of the medical record organize/integrate data relation among problems global picture of patient: avoid missing details legal communication: important as "health care team" expands to include many professions (PT, OT, RT, VNS) history "hypothetico-deductive approach" to diagnosis and treatment patient comes in with a problem collect data (history, physical, lab) analyze and interpret the data create hypotheses = "differential diagnosis" = list of possible diseases based on hypotheses, collect more data and try treatment strategy revise hypotheses based on data & outcome of treatment this process is reflected in the medical record, and serves to illustrate the structure and use of medical data Eg, physician's notes during a patient's hospitalization: 1. admit note: patient's problem and MD's initial plan 2. progress note: response to treatment, more data 3. discharge summary: summary of course, discharge plan 1. ADMIT NOTE CONSISTS OF: CC: "chief complaint" - a brief description of the patient (eg, age, gender, race, appearance) and a statement of why the patient came to the physician (in the patient's own words, if possible). This sets the context briefly, and focuses attention on the patient's problem. CC: 43 year old man in moderate distress who complains of "pain in my chest" HPI: "history of present illness" - a chronologic description of the patient's problem, followed by a list of "pertinent positives and negatives" that serve to confirm or eliminate diseases from the differential diagnosis. If the patient has more than one problem, the HPI is repeated for each problem. HPI: The patient was in good health until 4 days ago when he noted a mild, non-productive cough. Two days ago he began to develop rusty sputum and noted fevers, although he did not take his temperature. Today he noted severe pain in his right lower chest, made worse on inspiration. Patient has no history of asthma, bronchitis, or previous pneumonia. He denies diabetes, IV drug use, immunodeficiency disease. Drinks fewer than 2 drinks per week. He has made no recent long trips, and reports no leg pain. He smoked 1 pack of cigarettes per day for 5 years but quit 25 years ago. PMH: "past medical history" - description of previous medical problems. PMH: appendectomy at age 24. Otherwise negative. FH: "family history" - brief description of health of relatives, especially hereditary diseases. FH: Father died of myocardial infarction at age 65. SH: "social history" - brief description of patients social context, especially as it might affect treatment plans (eg, family support, money to pay for medications). Often includes occupation, smoking history, and alcohol use. SH: Lives with wife and 1 child. Drives a bus. (smoking and alcohol as above) ROS: "review of systems" - checklist of medical problems that may have been missed in the above discussion. ROS: neuro - negative respiratory - negative GI - negative GU - urinary stone passed at age 32 extremities - negative ... PE: "physical exam" - result of MD examining the patient. It consists of "signs," which are physical observations made directly by the MD or nurse (eg, temperature=101.0 degrees). These are distinguished from "symptoms," which are reported by the patient (eg, history of fevers). PE: vital signs: temp=101.0 F; BP=140/90; pulse=102; respiratory rate=29 HEENT: PERRLA throat clear neck: no venous distension lungs: clear on left dull to percussion over right lower lobe reduced breath sounds over right lower lobe [description often accompanied by diagram] no wheezes or rhonchi abdomen: ... ... Labs: "laboratory tests" - results of blood tests, urine tests, x-rays, and so on. Labs: PO2=50 PCO2=22 pH=7.50 WBC = 19 (67 seg, 20 bands, 5 lymph, 8 mono) HGB = 12.0 Na=141 Cl=101 K=4.5 HCO3=20 ... CXR: patchy density right lower lobe, normal heart, no comparison film available ... Impression: - summary of the patient's status and likely diagnoses. Impression: 42 year old man with history and findings consistent with acute bacterial pneumonia. Community acquired without risks for immune deficiency-related pneumonias. Doubt pulmonary embolism or infarction; doubt neoplasm. Severe hypoxia is present. Plan: - problem by problem list of actions (diagnostic and therapeutic) to be performed. Plan: 1. pneumonia: Admit due to hypoxia. Use ampicillin. obtain sputum culture, blood cultures admit to medicine 6 liters O2 by nasal cannula ampicillin 1 gram IV every 6 hours 2. anemia: relatively low blood count of unclear etiology. check stool for blood ... 3. hypertension: borderline high blood pressure, most likely related to stress of illness. repeat BP after acute illness 2. PROGRESS NOTE OR "SOAP" NOTE S: subjective - patient observations O: objective - MD observations A/P: assessment and plan - by problem 9/14/93 (Day 3) S: patient still feels poor, with continued coughing and chest pain O: T=99.7 F, max overnight 102.0 F lungs: dullness and rhonchi right lower lobe ... WBC=19 blood cultures = no growth sputum culture = Staph. aureus A/P: 1. pneumonia - continued fevers and high WBC. No apparent response to antibiotic. Sputum culture reveals S. aureus, which may be due to poor collection, or may be the pathogen. Will switch to oxacillin. discontinue ampicillin begin oxacillin ... 2. anemia - ... ... 3. DISCHARGE SUMMARY summary of patient's hospitalization discharge plan medications to take at home follow-up visits In addition to these physician notes, there are nursing notes, which contain more detailed information about the patient's daily progress and activities; flow sheets of information like vital signs; laboratory reports; administrative forms; and so on. related reading: Weed LL. Medical records that guide and teach. M.D. Computing 1993;10(2):100-14