(NOTE: These notes are quite complete. I'd say around 99% completed as far as what is included on the powerpoints which today he seemed to inform us of only what was on them. As far as the parts informing you about what will be on the test and the page numbers that is 100% accurate as far as what was on his slides. Hope this helps everyone with what they need to study plus he stated he will put up the list of more things to study on blackboard either today or tomorrow) Have a great Weekend!
Ch.2: Health Care Records
Medical Record Blunders
Rectal Exam Reveal a normal size thyroid (long Fingers?)
Exam of Genitalia reveals that he is circus sized
Patient was alert and unresponsive
On the second day the knee was better and on the third day…
House Questions:
Poiesis (formation)
-Genesis(origin or creation)
-gen(substance)
-iasis(healing) = -osis (condition)
-iatrics(practice of healing)
Today’s Lecture
History
Ancient medical records
Terminology
Overview of modern medical records
Hippocratic Texts: Epidemics
‘Case of Histories’-rough notes which record a patient’s symptoms/signs over a period of time
5th- 4th century BC
NB Epidemic= Gr. Epi- upon + demos – people or place
Individual signs and symptoms in chronological order. Very objective when writing their notes.
Endemic, epidemic, pandemic
In modern medical terminology what are the differences between endemic, epidemic, and pandemic dieases?
Endemic-a disease found in a specific population or region
Epidemic-The occurrence of more cases of specific disease than expected in a given area or among a specific group of people over a particular period of time.
Pandemic- A widespread outbreak of disease covering many geographic regions or the world.
Thucydides account of the plague of the Athens
Case histories as history
Thucydides (c. 460-395BC), historian of the Peloponnese war
Plague of Athens
Myasthma meaning they thought the air was bad and causing the sicknesses.
Galen’s Rhetorical use of case histories
Case histories as medical propaganda in 2nd AD
Galen On Prognosis
Remarkable diagnoses and prognoses
Pulse and lovesickness
Testimonies of Asclepius, Greek God of Medicine
Testimonies of cures
Propaganda or cure?
Placebo-L. “I will please”-1785 used for “A medicine given more to please than to benefit the patient”
Will come into the patients dream and either helped heal or told the priest how Asclepius told him how to be better.
What kinds of medical records you need to know for the test
History and physical : pp 41-43
Progress note (SOAP format) : pp43-44
Prescription : pp 73-76
What you need to know
What each form is form
What are the component parts of each form
What kind of information goes in each component part
The common abbreviations associated with these forms
History and Physical (H&P)
Document of medical history and findings from physical examination
History And Physical
Two major divisions:
History (Hx)
Subjective information-history obtained from patient including his/her personal perceptions
Physical examination (PE)
Objective information-physical facts and observations made by an examiner
Physical examination is tan
Blue is subjective information
know abbreviations on the side.
ROS-usually assume it goes into physical examinations, but it goes into the subjective information.
Profess note:SOAP format
Progess notes made after the initial history and physical recorded. The letters represent the order in which progress is noted
S: Subjective-that which the patient describes
O: objective-observable information, such as test results, blood pressure readings, etc.
A: Assessment- progress and evaluation of the effectiveness of the plan and prognosis, goals
P: Plan-decision to proceed or alter strategy
Progess notes look like
If you’re ruling out then you test for it to see if it is. Means your going to test for it.
Know abbreviations and what goes on there
Purpose of Progress notes
Evaluative
Important legal documents
Ensure proper patient care
Prescription
Physician’s written direction for dispensing or administering a mediciation for a patient
Must be written in a specific format
RX: Prescription
Dispensation: name, strength and amount
Signa: Patient instructions
Review what it looks like
q how many times needed
prn means as needed
Prescription symbol
Rx
L. Recipe-TAKE from recipere-to take
NB Prescription-L praescriptio=precept, rule, direction
Falcons eye not where Rx comes from
Signa
L. Signare-to make known or indicate
L. Signum
Vexillarium, imaginifer, signifier
Vex.:Carries a flag, banner, that has the name of the legion.
Ima.:image of the emperors face, to give courage in battle, looking after you or upon you.
Sig.: typically has a hand showing the oath, go back and would reorganize the troops.
-fer means to carry or to convey something
-phor –pher to carry barer
What tables you need to know for the test
Tables:
Common abbreviations used in the history and physical and progress notes pp 44-45
Disease terms pp64-65
Medical facilities and patient care abbreviationspp67-68
Routes of medication administration pp72
Common prescription and abbreviation and symbols pp74-75
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