Basic Job Description:



Duties and Responsibilities for Psychiatric and Psychological Technicians at Senior PsychCareVolume I PART IIIBIOPSYCHOSOCIAL PSYCHOLOGICAL AND PSYCHIATRIC TECHNICIAN’S GUIDE FOR MANAGERS WITH ORIENTATION AND STANDARD OPERATING PROCEDURESThis information contained in this manual is the property of SENIOR PSYCHCARE. It is not to be reproduced in any media without permission from Dr. Leo Borrell. Should the relationship between SENIOR PSYCHCARE and the provider be terminated for any reason, this manual will be returned to SENIOR PSYCHCARE within five (5) business days. This information is confidential and proprietary and property of SENIOR PSYCHCARE. In view of the nature of the material, it is understood that use of this material without permission would be detrimental to SENIOR PSYCHCARE and its employees and a violation of accepted professional business standardsMedical Scribe’s Guide First Edition was used as a resource as well as from other materials from Senior PsychCare TrainingDisclaimer: Scribe is a professional and legal term which consists of training and supervision. SPC does not provide this level of training and supervision. Because of this we do not use the term scribe only psychiatric and psychological technician. This guide is an informal description of the job of psychological technicians and psychiatric technicians. Additional material may be added from time to time.Senior PsychCare Dr. Leo J. Borrell, CEO Randy Frapart, CFOJudy Borrell, Secretary-treasurerDr. Tayfun Karakoc, Chief Medical Officer HoustonCorporate OfficeDallas Regional Office4635 Southwest Freeway, Ste. 635Dr. Elizabeth Klepper Corp. Clinical DirectorHouston, Texas 770272300 Valley View Lane, Ste. 330(713) 850-0049Irving, Texas 75062(214) 423-7777Houston Regional OfficeSebastian Laroche, Regional DirectorSan Antonio Regional Office4635 Southwest Freeway, Ste. 635Tom Forsberg, Regional ManagerHouston, Texas 7702785 Northeast Loop 410, Ste. 220(832) 370-5470San Antonio, Texas 78216(682) 234-9101Renee Fitzwater, Executive Director Dallas2300 Valley View Lane, Ste. 330Amanda Vasquez Executive Director AustinIrving, Texas 75062Coordinator Family Therapy(832) 597-380085 Northeast Loop 410, Ste. 220 SanAntonio, Texas 78216Diego Basagoitia, Director of IT and ComplianceGina Myers, Director HR4635 Southwest Freeway, Ste. 6354635 Southwest Freeway, Ste. 635Houston, Texas 77027Houston, Texas 77027(713) 850-0049(281) 733-1035Catherine Azodi, Compliance ManagerJerry Agua, Controller4635 Southwest Freeway, Ste. 6354635 Southwest Freeway, Ste. 635Houston, Texas 77027Houston, Texas 77027(281) 620-3686(248) 757-3822Houston Region StaffSan Antonio Region StaffJanet Arceneaux, PhD.Vinod Alluri, M.D.Olufunilola Atandeyi, NPLivina Akpunku, NPAbioloa Atobatele, NPBerthony Bien-Amie, NPSofia Beltran, PsychologistLori Blakely, LCSWNeedhi Bhaga, PsychologistGail Clark, PAShannon Boyer, PsychologistKendel Cohen-Selig, LCSWTerri Clark, NPJulie Gilmore, LCSWLeslie Crossman, PsychologistDavid Johnson, M.D.Perpetua Eze, NPRoxanna Medrano, NPTayfun Karakoc, M.D.Kellye Mixson, NPKrista Lewis, NPLawanda Myers, LCSWDaylong Long, NPAndrew Pratt, PAAde Omigie, NPLinda Pusateri, LCSWDiane Schaefer, LCSWEilen Reilly, NPMichelle Times, NPPaloma Solis-Garcia, NPPaul Wadler, PsychologistCynthia Stewart, LCSW-PTBridgit Williams, LCSWMonique Straker, NPVivian Young, NPAmanda Vasquez, LCSWStormy Valdesino, NPDallas Region StaffHoward Walker, LCSW-PTAmy Abadia, LCSWUzma Ahmed, M.D.Chima Asikaiwe, M.D.Shannon Campbell, LCSWMary Cannon, LCSWAmanda Chappelle, NPNancy Craft, LCSWKet Davis, NPTricia Davis, LCSWMary Edwards, NPTheresa Edwards, NPPeter Formusoh, NPVictoria Forsberg, NPNatassia Greer, PsychologistLoyce Hopkins, LCSWKyle Johnson, NPRebecca Korn, LCSWWendy Lewis, NPFrancheska Martinez, LCSWPeter Moenga, NPOfear Moore, NPAlisha Neal, LCSWTeressa Rashid, PAJennifer Rawley, PsychologistKendall Reese, NPTascha Reese, LCSWStephanie Stockton, NPJulie Thomison, NPDeborah Tome, LCSWLieu Vuong, PsychologistMarlon Womack, NPDenise York-Florez, NPVolume IPart IIIDuties and Responsibilities for Psychiatricand Psychological Technicians*This does not include all materials necessary for education and training in management of patients at Senior PsychCare. In order to obtain information regarding issues that might occur time to time, please refer to the protocols of medication management, mid-level guidelines, psychotherapy training manual and reference books.Job Description of a Psychological and Psychiatric Technician9Forward12A Psychological and Psychiatric Technician’s RoleWhat is Psychological and Psychiatric technician?14What is a technician not to do?14HIPAA16Patient safety and privacy19Technician safety20The House of MedicineWhat is a provider?22Specialties in medicine23Creating a NoteWhat is a note?30Templates, macros, and cloning31Anatomy of an ED Provider Note: An in depth examination of each part of a generic emergency department note, with a sample template to use as a guide. Includes specific billing requirements.Sample Template38Precharting40History of the Present Illness (HPI)44Descriptors (Billable Elements)44Review of Systems (ROS)48Additional History51Past Medical History (PMHx)51Family History (FHx)51Social History (SHx)53Surgical History (SHx)53Medications53Allergies55Physical Exam (PE)55Procedures58Medical Decision Making (MDM)59Synthesizing a History: A more in depth step-by-step exploration on how to create a history and treatment planning (see addendum).Historians and limitations60Language61Building blocks62Additional Roles of a Technician: A description of things a scribe may do (other than completing the note), including creating prescriptions, writing for orders, and creating dispositions.Prescriptions64Orders67Optional Practice: Optional practice for some of the skills discussed in this text, along with “answer keys” and tips for improvement.73Being a Successful PsychTech – Insight from Experience: Tidbits of technician advice given by experienced scribes working for ABC Scribe.79Treatment Planning… Neuroimaging in Psychiatry 83How to Make a Memory Box125Team Development and Coaching117Education of Nursing Home Staff129PART III ADDENDUMSpecialty Medicine130Descriptors Billable Elements133Review of Symptoms133Physical Exam133Key Points Example 1134Anatomy Guide: Anatomy a scribe should know, organized by system and explained with the aid of definitions and illustrations.Directional terms152EENT (eye, ear, nose, throat)153Endocrine153Lymphatic154Cardiovascular154Respiratory155Digestive155Genitourinary156Integumentary156Musculoskeletal156Nervous156Medical Terminology Index: A comprehensive list of medical terminology (with definitions) that are useful to know in a scribe’s line of work.Constitutional158HENT159Hematologic/Lymphatic162Endocrine163Cardiovascular164Respiratory166Nervous168Psychiatric171Medication Index: See SPC medication protocols pages ix-xv. A comprehensive list of the most frequently encountered medications. The list is classified into property-based medications, and system-based, and organized by “broad grouping” and “drug class”.Psychiatric172Pertinent Questions: A list of common chief complaints in the emergency department, as well as possible differential with pertinent questions that the provider will likely ask. 175Chapter 1: Job Description of a Psychological and Psychiatric TechnicianPsychological and Psychiatric Technicians and clinicians should discuss minimal data set to share information on FAST Scale and MOCA and if patient has not been referred for psychiatric or psychological consultation discuss with the Nurse Practitioner and Regional Manager if a referral is appropriate based on their score on the BMS and PHQ9 as an indication of depression.Basic Job Description:Care for mentally impaired or emotionally disturbed individuals, following physician instructions, protocol, other reference material and hospital procedures. Monitor patients' physical and emotional well-being and report to medical staff, psychological staff and managers. May participate in rehabilitation and treatment programs, help with personal hygiene, and administer oral medications and hypodermic injections.This is not a complete list of duties thus additional responsibility may be assigned from time to time by your immediate supervisor and other management personnel.The psychiatric and psychological technician if under the direct supervision of the Psychiatrist, Nurse Practitioner, and Regional Manager. The technician is not to assist the psychotherapist unless approved by the Regional Manager and Senior Management.Job Activities for: "Psychiatric Technician"1)?Documenting/Recording Information?-- Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form.2)?Communicating with Supervisors, Peers, or Subordinates?-- Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person.3)?Resolving Conflicts and Negotiating with Others?-- Handling complaints, settling disputes, and resolving grievances and conflicts, or otherwise negotiating with others.4)?Assisting and Caring for Others?-- Providing personal assistance, medical attention, emotional support, or other personal care to others such as coworkers, customers, or patients.5)?Getting Information?-- Observing, receiving, and otherwise obtaining information from all relevant sources.6) Organizing behavioral rounds – All persons to attend you must inform the PCP and others and make a schedule of rounds.7) Organizing activities of professionals – To be efficient and coordinate activities of professionals, inform nursing home staff, other physicians involved in care, and patients to be seen. Check with nursing home staff regarding new patients or get information about a change in conditions in order that patient is available for re-evaluation.Skills Needed for: "Psychiatric Technician"1)?Active Listening?-- Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.2)?Writing?-- Communicating effectively in writing as appropriate for the needs of the audience.3)?Reading Comprehension?-- Understanding written sentences and paragraphs in work related documents and assure that notes are legible, grammatically correct, consistent with medical guidelines and standards of care. Notes must be completed and filed in the chart in a timely fashion (48 hours) or guidelines communicated with staff or nursing home staff. (see Texas Medical Board guidelines)4)?Social Perceptiveness?-- Being aware of others' reactions and understanding why they react as they do and your own non verbal communication and messages that you may be communicating. Be aware of social and professional norms. If you are not clear of them, feel free to discuss with your supervisor and/or request a meeting or conference call or input from your coworkers. Phone contact is preferred because we are a virtual company and face to face meetings may require driving, more additional time, or interfere with others priorities. These calls and meetings are to be approved by your immediate supervisor and regional manager to plan ahead of time.5)?Speaking?-- Talking to others to convey information effectively6) Team Work – inform patients of their progress and identify problems that may have been overlooked.Abilities Needed for: "Psychiatric Technician"1)?Oral Comprehension?-- The ability to listen to and understand information and ideas presented through spoken words and sentences.2)?Problem Sensitivity?-- The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem and then propose a solution. The formula for this is plan, act, and review then re-plan.3)?Oral Expression?-- The ability to communicate information and ideas in speaking so others will understand you. If someone is hard of hearing or has other handicaps those should be declared and explained. That information is useful for team work which involves communication, clarification, and coordination.4)?Speech Recognition?-- The ability to identify and understand the speech of another person. It is important to speak clearly so others can understand you. If you are aware of limitations, discus with your immediate supervisor and HR to improve your capabilities.5)?Speech Clarity?-- The ability to speak clearly so others can understand youMid-level job descriptionTo provide appropriate medication to manage physiologic metabolic activities that effect bodily function and ability for optimum psychosocial function. This is not either or but both require the attention of the team and development of treatment and collaboration of treatment team to develop a treatment plan that addresses all facets and a decision made of professionals who have knowledge under the direction of collaboration and supervision of qualified doctors including staff and family and others who can approve the care and functioning of the patient. It is a complex ongoing process to be monitored and modified based on the benefits to patient care and improvements of biopsychosocial functioning.CHAPTER 2: FORWARDDear Reader,This training guide was born of the need for a concise handbook or guide to the key elements required to be a great psychological and psychiatric technician. It is a compilation of ideas and skills gathered over years of experience. It is not an exhaustive compendium of things that you will ever need to know, but it will help to answer some quick questions that will aid you in becoming a more effective and efficient technician. If you are aware of things that were not taught, please inform your immediate supervisor, regional manager, and the human resources department. Dr. Leo J. Borrell, your principal author in this endeavor, has extensive experience identifying the skills needed to assist professionals and function as an excellent team member in many settings, including nursing homes and assisted living, both inpatient and outpatient settings, as well as several specialties. He has organized this handbook in a way that should make it useful both as a study guide, as well as a handbook that can be carried with you as a quick reference while on the job. In addition this material is available on our server and you should be informed at onboarding of this.If there is incorrect information or if you have a question about the material, please submit in writing to your supervisor, corporate clinical coordinator, COO, compliance officer, and human resource director and clinical manager. Confirm that issues have been resolved within ten days. If not, request group discussion with above mentioned individuals. It is important to obtain a list of new patients on visit to nursing home or assisted living to determine if they need a referral (see screening template). This is to facilitate better understanding and management of clinical issues and improve and standardize care. Each NP/PA and district manager should do check list of important routine activities and unique expectations for every facility and work schedule approved by direct supervisor.Leo J. Borrell, MD CEORandy Frapart, COOElizabeth Maynard, Chief Corporate ClinicalCHAPTER 3: A PSYCHOLOGICAL AND PSYCHIATRIC TECHNICIAN’S ROLEWHAT IS A PSYCHOLOGICAL AND PSYCHIATRIC TECHNICIAN?A psychological and psychiatric technician is a documentation assistant to the medical provider and members of our team and employees. Documentation is done in the electronic medical record (EMR), also known as the electronic health record (HER), which is a computerized healthcare platform. (see training manual for use of EMR).A technician’s role can include a variety of activities. The technician’s primary role is to assist the professional and to listen to the provider while they are obtaining the patient’s history, the Mental Status Exam and the form the history of the present illness (HPI). As well as coordinating care and education with nursing home staff and family. This is coherent story, usually chronologic, describing the patient’s present illness from the first sign or symptom ot the present. The technician may also complete the review of systems (ROS) and Mental Status Exam after the history has been taken. This is a review of the symptoms that a patient may have, which is also obtained by the previous medical provider. A technician may do other things if specifically told by the provider. These include recording the physical exam (PE), which consists of the provider’s physical findings on that patient. The technician may also enter orders for labs, tests, or imaging into the electronic medical record. At the provider’s request a technician may document procedures, the result for certain tests (like Montreal Cognitive Assessment Scale, the FAST scale, and Mini Mental Status), or complete the “paperwork” for the patient’s disposition and follow-up instructions. Meet with the minimal data set coordination to obtain PHQ9 and BIMMS Brief Mental Status Exam and compare to FAST Scale and other assessments of mental function. Schedule all behavioral rounds at least quarterly and summarize activities.Psychological and Psychiatric technicians are one of several solutions that allow the physician to document more accurately, more thoroughly, and more efficiently. As an example, a provider may require five minutes to document on a patient encounter. IF they see thirty patients in a shift, that would amount to roughly 150 minutes (or two and half hours) of time lost to documentation. With a technician, the chart should be completed more or less when the provider exits the patients’ room or before the PT or Provider leave the facility. Time and money are saved, and the chart that the technician completes will likely be more thorough and accurate than the one the provider will create based on memory alone. We only remember 50% of what we memorize in the first 24 hours.A psychological and psychiatric technician is the provider’s partner in documentation. The technician may have to ask questions to clarify what they didn’t understand, and to prompt their provider to provide elements of the history and physical exam that were not heard or observed. A technician should never be afraid to do this… at an appropriate time. This ensures accuracy and is a part of the technician’s value to the provider. A technician should also help the provider meet billing requirements. Technicians are expected to inform the provider if billing requirement are not met, and prompt them to obtain more elements to complete the chart and make sure patients are available when a person is scheduled is available. The provider and psychtech should discuss and rate their performance and identify problems and methods to improve performance and discuss with other team members and share their experiences with others and with regional managers and ask for help dealing with repetitive or severe problems for which you have no solution.At the beginning and end of the day, the technician should meet with a professional to improve documentation (see procedures for Huddles in Resource Manual). This helps to improve patient outcomes. Technicians allow the provider to spend more time with the patient and less with the computer. They create an accurate document for other providers to consult by performing immediate documentation so details aren’t forgotten. They ensure that the document they create is billable to all standards so the provider may be paid for his/her work. If there are any questions, the billing department or compliance department should be contacted, and lastly, they document details that are necessary for audits that ensure quality care.WHAT IS A TECHNICIAN NOT TO DO?A technician is considered as “non-clinical” personnel, meaning that there are a variety of clinical activities in which a technician may not participate.It is stated that a technician either observes or listens to their provider prior to completing any element of the chart in the section above entitled “What is a P & P technician?”. This is because a technician cannot elicit history from the patient themselves, nor perform a physical exam but they may clarify misinformation or lack of information. A technician is limited to assist in performing medical procedures this depends on training and supervision by supervisors and SPC policy and nursing home policy and Department of Aging and Disability (DADS) regulations. They also may not assist other healthcare providers in gathering supplies or administering medications. There are certain safeguards in place in the electronic medical record that allows the technician to act as non-clinical personal. These include “hard-stopes” after a scribe places orders or creates prescriptions. The hard-stops prevent the order or prescriptions from being acted upon unless the provider has reviewed, approved, and signed the technician’s work. In addition to the hard-stops, the electronic medical record should also send notifications to the provider (like medication contraindications such as allergies or drug-drug interactions), even if they were sent to the scribe first. Considering the restrictions in the electronic medical records placed on a technician, logging onto the computer using the physician’s badge is never acceptable, and in fact, constitutes fraud unless approved and supervised clinician.A technician must be both an excellent listener and an excellent communicator (see Bedside Manners) in order to be a successful part of the healthcare team. Most of the technician’s communication is written and done by documenting the encounter in the electronic medical record. A technician may also communicate with other members of the healthcare team, but with certain limitation. A technician may call other providers to give them patient and family’s information, or transmit verbal orders to other healthcare providers. However, they can answer simple questions, such as whether the provider has been in to see a patient, or identify the provider’s current location in the department or medical facility based on HIPAA, SPC guidelines, DADS and regulations. For complex questions they should discuss with the provider and provide answers in writing approved by a professional or supervisor.The technician may interact with patients, the nursing staff, families, and the business office: the patient may ask for a warm blanket or a drink, or ask questions about their health care. The technician may almost always get patients warm blankets, but must ask the provider if the patient is allowed to have any oral intake (“po” or “per os” intake). There are a variety of reasons why this may not be allowed, including concern for stroke (choking hazard), or the patient may be a surgical candidate (vomiting hazard). If a patient asks any questions that are medically related, the scribe should politely defer to an appropriate member of the healthcare team to provide an answer in written form or email. Since a technician is a non-clinical part of the healthcare team, they are not trained to answer these kinds of questions but may relay information from the professionals and should not be reluctant to state they do not know the answer particularly specific to the patient. The Psychological and Psychiatric Technician may be assigned periodically to assist Psychotherapists based on the need determined by the district manager or corporate office. If this occurs, they should request training on psychological issues from district manager and immediate supervisor with documentation.In summary, there are two general rules to heed; 1) a technician may not touch anything but the keyboard; 2) other than the open communication that is expected between technician and provider, a technician should always keep their other communications limited to the subject at hand. Always use common sense, but when in doubt, ask: “is this a clinical or non-clinical function?” or consult with your supervisor. Be willing to accept corrections in training as long as it is done with respect. If not done with proper respect and you think it is inappropriate discuss with your supervisor, regional manager and provide written documentation if it is repeated incidents or severe. This applies not just to employees of SPC.Please consult with the compliance department, clinician, and district manager to clarify any concerns.HIPAA (HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT) (See Compliance Procedures in Resource Manual)HIPAA is federal law imposed on all healthcare providers and their affiliates to regulate protected health information (PHI), which is any healthcare information that can be linked to an individual. Essentially, HIPAA forbids unnecessarily sharing any identifiers that may link a patient to their health information. “Identifiers” may include, but are not limited to : name, age, email, SSN (social security number), address, phone number, MRN (medical record number), etc. Understanding the HIPAA law in some detail is important for anyone who works in healthcare and for patients safety and privacy.Healthcare organizations are known as covered entities, meaning that the law directly covers their actions. A covered entity must have in place appropriate administrative, technical, and physical safeguards to protect the privacy of protected health information. The law also however extends to other companies that work closely with healthcare organizations, which are called business associates. If a covered entity contracts with another company that provides them with a service, and thus may have access to protected health information at any time, the covered entity must have a contract with this other company, the business associate. That contract must state what the business associate will be doing on their behalf, and that the business associate must also comply with HIPAA rules regarding protected health information. An example would be a doctor’s office (the ‘covered entity’), which is subject to HIPAA rules, that hires a psychological and psychiatric technician company (the “business associate”), which will have access to protected health information and must sign an agreement outlining their role and responsibilities under HIPAA.There are specific rules that comprise HIPAA law (see SPC Compliance HIPAA):Privacy Rule: Provides federal protections for any oral, written, or electronic protected health information, and gives patients an array of rights with respect to that information.There are some permitted uses of protected health information that do not require direct authorization from the patient. Some of these circumstances include sharing information in order to obtain payment or reimbursement for healthcare services, or to perform any necessary healthcare activities like the patient’s treatment plan or any operation necessary for business. Researchers are also allowed to access and use protected health information when necessary to conduct research. HIPAA only applies to research if the research is actively being used in patient care in such a way that the researcher is establishing a provider-patient relationship with the patient. In those cases, it crosses the boundary from pure research into the realm of treatment, which is thus covered by HIPAA. ( See SOAP notes Chapter 5)Security Rule: Covered entities must use technical and non-technical safeguards to secure electronic protected health information (ePHI). This includes maintaining reasonable and appropriate administrative (rules), technical (electronic security measures), and physical safeguards. Physical safeguards may include measures taken to protect against natural and environment hazards (like floods), unauthorized intrusion (like locks), workstation use and security (tap badges or fingerprint biometric identification), and device and media controls (controlling access to computers and storage devices).Specifically covered entities must ensure the “confidentiality, integrity, and availability” of all e-PHI they create, receive, maintain or transmit. In short, the healthcare entity must take all reasonable precautions against any potential violation of the privacy of the patient’s medical records that could be anticipated.Any healthcare provider who transmits ePHI is covered by the Security Rule. Many of the stipulations of the Privacy Rule apply under the Security Rule as well. The ePHI should not be disclosed to unauthorized persons (keeping confidentiality), the information should not be altered inappropriately (maintaining integrity), and the ePHI should be accessible by authorized persons (maintaining availability). It should be noted that these rules and guidelines apply not only when employed but subsequently when individuals terminate their employment. This information is also protected for non compete and solicitation.Breach Notification Rule: If there is ever a breach of security of a patient’s protected health information, that patient must be notified. (see guidelines)Patient Safety Rule (confidentiality provisions): This provision provides protection to those who voluntarily provide information regarding patient safety to organizations that analyze this information to make efforts to improve patient safety.As member of the healthcare team, technicians are always subject to HIPAA laws. Violations of HIPAA may result in large fines and/or time in jail. Unintentional violations may include an unattended computer that is logged into the electronic medical record, or papers with patient information left in a workspace or discarded in the waste bin (instead of the shred bin). A technician should also avoid sharing protected health information about a patient unnecessarily, discussing protected health information in a public area, looking up information about a patient that is not pertinent for the job, browsing through one’s own medical records or the records of friends or family, or even sharing that the patient was seen in any medical facility. Information is shared only on a need to know basis and one should be careful about disclosing information in public places or on the phone.It is useful to consider an example of how HIPAA would work in an emergency department. A technician will undoubtedly want to share some of the excitement that occurs in the department when they go home. It is certainly permitted to discuss certain things in a very generic way. For example, if a patient had a collapsed lung and needed a chest tube, then sharing that you got to see a chest tube insertion would be permitted as long as nothing is stated about the patient and only the procedure is discussed. In other words, health information in the absence of patient identifiers is generally considered to not be protected under the law. On the other hand, if a patient is evaluated for anything that may be reported in the newspapers, then the technician may not mention anything about the case, lest it be connected with a specific person. A rape case would be an example (meaning a legal case, this a “forensic case”). A celebrity seen in the emergency department would also be a case that could not be discussed, even indirectly. When in doubt, keep it to yourself. (see DADS regulation regarding neglect and abuse, and patient rights)PATIENT SAFETY AND PRIVACYIt is important for a patient to be properly identified in health care situations. This is for their protection under HIPAA, as well as for their safety in any situation where they must be identified correctly. If a patient has a common name, then date of birth and middle name may be used to identify the patient. There are many other allowable identifiers such as account number, social security number, and address. Identifiers such as patient room number, complaint, or referring physician are nonspecific and should not be used to make a positive identification.Not only should the technician follow the rules set by HIPAA, the scribe should also be cognizant of a patient’s personal privacy. In the emergency room, for example, many patients are asked to change into gowns and stay in rooms separated from the rest of the department by glass doors and/or curtains. Please remember to be considerate of a patient’s privacy when entering or exiting a room, and shut the door or curtain. A good rule of thumb in respecting a patient’s privacy is to consider how you would like to be treated if you were in their shoes (or wearing their gown!). Employees are not allowed to accept gifts or monetary reward from patients or employees of other companies an exception can be made on a case by case basis by regional manager.TECHNICIAN SAFETYA technician may be faced with different types of security challenges in the healthcare setting. The most dangerous area of all would be the emergency department. Violent criminals, their victims, and psychotics all tend to come to the emergency department from time to time. Many patients have impaired behavior due to alcohol or other substances as well.Most health clinics will have some sort of security present. Security personnel typically become involved in any dangerous situations. When you go to a new facility be aware of your facilities security plan. Be aware of your facility’s security plan and any role you might be required to play. In theory, your physician will know these things. But in practice, they could be new or a locum tenens (temporarily in there to fill a vacant position), and thus will not be as familiar with that emergency department as someone who has been there many years. Safety in the health setting encompasses more than just security situations. Working in a medical setting (especially in the hospital), you must be aware of exposure to infectious disease. There are many viruses and resistant bacterial strains that could pose a risk to healthcare workers.Health clinics will require that anyone working in the facility be vaccinated or tested for certain common illnesses like the flu or cold (e.g. tetanus, influenza, Hepatitis B, and tuberculosis). These requirements vary between healthcare facilities. Additionally, there are universal precautions that healthcare workers must adhere to for preventative safety. These include the use of gloves when touching bodily fluids, hand washing or using alcohol foam when entering and exiting a new patient’s room (“foam-in, foam out”), avoiding sharing our “germs” with others (“cover your cough”), and regularly disinfecting surfaces and rooms. You are responsible to minimize transmission of infection.Some infectious disease patients may be identified as “higher risk” and may have additional safety precautions in isolation. Healthcare workers may be required to wear personal protective equipment (PPE), like a gown, gloves, and a mask while in the room. Sometimes they will also need to wear shoe covers and leggings. A “respirator” (air filtration mask) may be required in rare cases. Because technicians are considered as “non-essential personnel,” meaning their presence in the room is not necessary for patient care, there is no reason for a technician to enter the room of high risk patients.Although a technician should never have to worry about touching body fluids, there is still a risk of exposure associated with being in any healthcare setting. For example, if body fluids land on intact skin, the area should be washed, but otherwise poses no concern f r transmission of infectious disease. If a patient’s bodily fluids come into contact with a break in your skin or with your mucous membranes (like the eyes or mouth), the technician should ask their provider or charge nurse what the policy is regarding how to proceed and notify your supervisor about SOP.CHAPTER 4: THE HOUSE OF MEDICINEWHAT IS A PROVIDER?For the sake of simplicity, there are two types of “providers”: physicians and NPPs (non-physician providers). Non-physician providers include nurse practitioners, physician assistants, clinical nurse specialists, Psychologists, PhDs, LCSWs, LNPs, LPCs, and more. For our purposes, in most instances, a “provider” will be a physician or ib some cases a NP (nurse practitioner) or a PA (physician assistant). The primary role of the technician is to assist psychiatrists, NPs, and PAs. They may assist psychological providers with written permission by the regional manager.Providers may work in a variety of areas in medicine. They may work in primary care, which requires one to become a “jack of all trades,” and know a little about all areas of medicine. Alternatively, they may work in mental health which requires one to know a lot about a specific area of medicine.As a psychological and psychiatric technician, you will often hear names of many providers in different areas of medicine who are all participating in one patient’s care. This is because they all have the training necessary to meet on (or more) of that particular patient’s needs. For example, one patient may be following with a urologist for their recurrent urinary tract infections, a c cardiologist for their hypertension, and a rheumatologist for their lupus. Generally, the primary care provider acts as a “quarterback” of sorts and coordinates patient care amongst all of the other providers. He may overrule decisions of others. If this occurs this should be discussed with attending psychiatrist and regional manager, nursing home staff, and administration. If it is a danger to patients and others this would influence timely intervention.This chapter examines many areas of medicine, divided into two categories: primary care and specialty medicine. It is always important to document the names of the providers with whom the patient follows, along with their areas of specialty. This allows the provider with whom you are assisting to consult the other providers who are familiar with that patient, and are thus more capable of providing quality healthcare. It also is the duty of the technician to translate the lay terms that the patient may use for the “type” of provider to the appropriate medical term. For example, substituting “cardiologist” for “heart doctor,” and “nephrologist” for “kidney doctor”, psychologists, psychiatrist, PhDs, social workers, LCSWs, and LPCs, and so forth. SPECIALTIES IN MEDICINE THE PSYCHOLOGICAL CONTRACTLevinson, Harry, Price, Charhon R, Munden, Kenneth J, Mandl, Harold J, and Solley, Charles M. Men, Management, and Mental Health, Cambridge: Harvard University Press, 1962.People unconsciously pick and choose work organizations which support their psychological defensive structures, help them meet the requirements of their ego ideals, are likely to enhance their self-images, and conform to the requirement of their superegos. It is commonplace, for example, that people who seek security will not go into independent selling, that entrepreneurs will not be satisfied in a heavily bureaucratic setting. Thus people come to organizations with reasonably well-defined expectations of them, reflected in its job descriptions, goals, division of responsibility, and so on. There are also many tacit expectations which are taken for granted, like not taking drugs on the job, or being at work when there are major responsibilities to be discharged, regardless of the weather.However, as was first discerned in a study in the Kansas Power and Light Company, the expectations of both the individual and the organization go much deeper than had been understood before, far beyond the manifest content of wages, hours, working conditions, and fringe benefits on the one hand, and job obligations on the other. If people are always striving to maintain their psychological equilibrium while working for their bread, then they also seek support and gratification in the organization for their deepest psychological needs. Because these needs are continuously pressing, individuals bring them to the organization with great intensity, though they themselves may never be aware that they are doing so.In its expectations of managerial candidate, the company idealizes the prospective candidate and expects perfection and continued top performance. It expects the person to be apolitical personality, to go along with decisions even if he or she does not agree with them. It expects to be able to depend on the person to stay in the organization (at least a reasonable length of time), to accept whatever higher level managerial decisions are made, not to manipulate people against the organization’s needs or take advantage of the organization’s dependency on him or her, not to threaten others or to compete too openly, and certainly not to produce scandal that would reflect negatively on the organization. It expects the person to wait for promotion, not to run away if he or she does not get it on time, to stay with organization through thick and thin. It expects him or her to seriously consider different assignments, to move, if necessary, and to accept reassignments cheerfully. It expects the person to be available when he or she is needed and not off some place on holiday, or to come back if her or she is on holiday. It expects the person to act on the company’s behalf: not to give away or sell its secrets, and not to exploit others or take advantage of other people in the company. The manager, to take an extreme case, who spreads spies throughout the organization, who insists on personal loyalty above the company loyalty, who threatens people with vengeance if they squeal on him, who insists that his subordinates are his servants and must accept and recognize that when they come to work in his division- this manager clearly violates these expectations on the part of the organization.Managers’ and executives’ expectation of the organizations are multiple also. Many expect a shot at the top position, however unrealistic that may be. Most of the expect line operating responsibilities even though they are in staff roles, and they expect the company or higher level management to understand their ambitions even though those ambitions are largely fantasy. They expect to be told about judgements being made about them, that they will not be kept in the dark, that the organization will not play games with them, that it will not hold mistakes against them, that it will live up to what the recruiters or headhunters told them, that the image of the company is indeed the way the company behaves, and that the way in which they are treated will enhance their personal status and relationship vis a vis others in the company as well as in the community. These status enhancing benefits may include country club memberships, automobiles, and other kinds o perquisites which are not seen by the compay as having to do with status but rather as serving a practical functions. However, when the company moves to take any of these benefits away, ti becomes very clear that they have much to do with status, and service enhancement is only a very minute part of them. Every manager and executive expects the company to deliver these benefits if he or she plays the game the company way. Implicitly the bargain is ,”Don’t hurt me.”None of these expectations are specified in any of the negotiations between the superior and the subordinate, between the company and the prospective manager who comes aboard. Yet all of them are powerfully embedded in the relationship. There is a whole set of organizational expectations and a whole set of employee expectations, many of which are not conscious – although some are preconscious and some are conscious. Those expectations that have to do with supporting the character structure of the individual are largely unconscious, and those that have to do with identification of the individual with the organization’s philosophy of management (with the capitalistic system) are implicitly assumed by the organization.These unconscious mutual expectations are held almost as rigidly as the expectations in a marriage contract. That is, each party acts as if his or her expectations should be fulfilled – even though the other party may not be completely aware of what they are. Each assumes that the other has made certain commitments (the employee particularly makes this assumption in terms of his or her psychological needs); and should one party not meet the expeectations, the other reacts as if the contract had been violated.There is, therefore, in every working relationship a psychological contract between a person and the organization in which he or she works.The psychological contract has many qualities which testify to its uniqueness. It is largely implicit and unspoken; much of it is unconscious. In many respects it antedates the formal and signed relationship between the employee and the company. It encompasses a mutual recognition that each needs the other to succeed. It is dynamic in quality in that it is constantly changing. For example, the organization makes a large initial investment in the individual in order to train him or her. This is usually followed by a long period of time during which the individual makes a large investment in the organization by serving it with his or her acquired skills. Finally, in an employee’s twilight years, there is often a period of time when the organization demands less of the individual and the individual is able to give less. This also happens throughout employment when the individual is temporarily disabled by sickness or accident.The psychological contract is dynamic in quality with regard to the organization, too. In order to streamline itself so that it can meet competition, the organization has constantly changing needs for new products and services in response to fluctuating market demands; for relocation of physical plants and personnel; and for shifting of administrative responsibilities.The nature of the psychological contract tends to hinge on the individual’s internal personality structure (what kind of psychological defenses he uses, the nature of his superego) and the “corporate personality” or “organizational personality.” That is, certain kinds of people are drawn to and attracted by certain kinds of organizations; and each organization has its own characteristic way of operating, its own self image, and its own value system.Along this line, think back to a time in your life when you were applying for a position. Many of us have shared a common experience. We considered two or more organizations, filled out pre-employment application forms, and were interviewed. We may even have been subjected to various aptitude tests. While we were being appraised, we were also appraising each organization. Often the nature of the job, the salary, and the opportunities for advancement were quite similar. Yet we had different feelings about each organization – some of them feelings that we could not specifically define. Sometimes we liked one organization much more than the others, and sometimes we disliked one intensely.In short, we were attracted to an organization for many reasons beyond our immediate awareness. When a person takes a job, he or she brings to the organization the implicit assumption that the organization will permit him or her to continue to manage his feelings of love and hate, dependency needs, and ego ideal in ways customary for him or her. If the organization has established characteristic ways of carrying on its business – e.g by pleasing the customer - then it assumes the employee is agreeing to do this when he or she takes the job. PSYCHOLOGICAL AND PSYCHIATRIC CARESenior PsychCare provides comprehensive care using a team approach of psychiatrists, nurse practitioners, physician’s assistants, PhDs, LCSW and LPCs. They provide valuations of biological, psychological, and social issues. Psychiatrist, PhD, LCSW, LPC: Cares for patients with mental illness. The role of the psychiatrist in the nursing home. We may conclude that there is a high prevalence of psychopathology among nursing home patients and that this psychopathology manifests itself in symptoms and behaviors that are distressting to patients and that are problematic for their cregivers to manage, many of who are undertrained and inexperienced. Ath the same time, lower grade but pervasively debilitating dysfunctions are often neglected. This situation present the psychiatrist with an unrivaled scope of practice of which the ultimate goeals are “the maintenance of functional capacity delayeing the progress of disease where possible; the creation of a safe supportive environment that promotes maximal autonomy and life satisfaction (Borson et al. 1987, p. 1412).In addressing these tasks, the roles or functions for which the psychiatrist may be called upon include the following:Making accurate diagnoses of complex psychiatric disordersAssessing medical psychological, and social factors that affect patients’ functioningApplying specialized knowledge and skills in the use of psychoactive medications in this age group, including their efficacy, adverse effects, and interaction with other medications that the patient is likely to be takingDocumenting assessment and treatment recommendations clearly and concisely, with the needs and nature of the referring staff and physician in mind at all timesProviding comprehensive and integrated treatment planning, working with the primary care pshycian and other members of the multidisciplinary staffBeing proficient in the use of the correct diagnostic and billing codes and the proper documentation thereof, in line with Medicare and Medicaid rules and regulationsOrganize behavioral rounds and the huddle as needed (see Resource Manual for huddle)Consider compliance with providing Incident 2 care by LCSWS or LPCs consistent with CMS and Novitas guidelinesAside from diagnosing and treating psychiatric disorders among the individual patients in long term care facilities, the role of the psychiatrist in the nursing home should include educating and supporting families, primary care physicians, and staff. The scope of this function may include the following activities:Encouraging new and appropriate referralsHelping staff recognize mental disorders and perceive the patient’s symtoms in the context of a medical disorder rather than as willful misconduct, personality traits, or a lack of cooperationReducing problems that cause emotional or behavioral problems in patients through better preventative measuresReducing probmes that cause emotional or behavioral problems in patients through better preventative measuresReducing the transmission of myths about mental illness, aging, psychiatric medications, and other psychiatric treatmentsProviding in service training to nursing staff, physicians, and administrationAssisting in ensuring compliance with federal and state regulations governing the medical care provided in the particular settingResolving conflict among staff and collaborating with mid levels and nursing home staff assuring collaboration of care which is nursing home staff and psychotherapist collaboration of care that must occur on the nursing home unit and is part of the face to face interaction for which there is no additional compensation unless it is part of a billable service. (see conflict resolution protocols)Primary Care is the area of medicine that is generally considered to be the first point of contact for the patient in caring for their general needs. Included in this group of primary care are the following areas:General practitioner: Antiquated term for the doctor who “did it all.” No specialty residency was required. These providers used to deliver babies, assist in, or perform, common surgeries, and provided care for everyone. Family Physician: This is the “newer” general primary care practitioner. A residency in family medicine is typically completed. May or may not deliver babies and assist in surgeries. Takes care of pediatric patients as well as adults.Internist (internal medicine): This is a general practice physician similar to the family physician, but has not trained to care for pediatric or OB/GYN problems.OB/GYN: some would call the gynecologist a primary care provider for women.Pediatrician: Specializes in the care of infants and children and adolescents. There are many subspecialties in pediatric medicine (included pediatric cardiologist, pediatric gastroenterologist, etc.)Gerontologist: Specializes in the aged and their issues. This is a relatively new specialty.Emergency medicine (often compared to primary care): Takes care of emergent issues. Does not necessarily try to diagnose, but rather looks for things that could acutely harm a patient and provides lifesaving intervention if needed. We often refer patients to ERs after hours or when not available because we only provide consulting services and are not on call 24/7 days. The PCP is responsible for those activities and our staff assists the nursing home and family or PCP on proper care.Urgent care (often considered primary care): Provides “urgent” care for lower acuity issues, like common colds or minor skin infections. If a patient needs a more in depth work-up, they are sent to the emergency department.CHAPTER 5: CREATING A NOTEWHAT IS A NOTE?A note is an entry made by the healthcare worker into medical record that describes the worker’s activities as they relate to that patient’s care. A provider note is any note created by a medical provider. If a scribe creates a note for a provider, it must carry a statement that identifies the scribe who created the note, be “taken over” by the clinician, and include a statement that the provider reviewed the note for accuracy and accepts it as their own. This helps to ensure that the scribe is never legally liable for the content of that note.All complete notes must be submitted and signed within 48 hours or the provider’s pay may be delayed. (see Texas Medical Board guidelines) It is the responsibility of the technician to place a note in the chart prior to leaving the facility.If the technician documents legibly (if on paper) and accurately, times and dates the note (if not done automatically by the electronic medical record), and prepares and completes the note for the provider to authenticate, then the technician has assisted the provider to meet Centers for Medicare and Medicaid Services (CMS) requirements for a complete medical record. Illegible handwriting creates liability for providers and others on the team and is unacceptable because it can jeopardize the health and safety of a patient.There are endless types of notes. The following are some of the most common ones that you might encounter:Complete history and physical (H&P): This is a full detailed note that reviews all of the traditional parts of a medical note, including (but not limited to): chief complaint (see referral form and Mental Status Exam), history of the present illness, review of systems, past medical history, family history, social history, past surgical history, medications, allergies, physical exam, labs and imaging (if any), and the assessment and plan (also known as medical decision making) and treatment plan which is updated every month to every six months.Attending note: The technician may be completing a note for the attending who is supervising others in the healthcare setting. If another licensed provider is seeing the patient in conjunction with the attending physician, then a brief note may be all that is needed (also sometimes called an “attending note”). This is a note that contains the important elements of history and physical, and any discussion that shows that the attending was involved and coordinated the care of this patient along with a resident, physician assistant (PA), or nurse practitioner (NP). It is a more abbreviated version of a complete H&P. A medical student may not create a primary note for an encounter. A medical student is not licensed to practice and thus their notes are for educational purposes. If a patient is being seen in conjunction with a medical student, the provider must create a complete H&P on their own. An attending note will not be sufficient, in this case. It must be signed and roles and responsibilities clarified. Brief note: A truncated note that contains only the essential elements for a simpler visit where the entire review of systems and physical exam need not be done. Essentially, a brief note has many of the same elements of a complete H&P, but is a more concise version. Procedure note: A note specifically for documenting psychotherapy or management of behavioral or psychiatric problems.. There are specific elements that should be included, further discussed in the “Procedures” section of Chapter 5.Subjective, Objective, Assessment, Plan (SOAP) *Request resource manual for management of psychiatric and behavioral problems: Often used on daily rounds on the floor of the hospital, or in an office setting for a patient’s regular follow-up visits. The “subjective” is equivalent to the history of the present illness, and the “objective” is equivalent to the physical exam. The “assessment and plan” portion is unchanged. This may sometimes be referred to as an APSO note, which is essentially the same thing but with the elements arranged in a different order. SPC has nursing home notes. If they desire to use ours they will have to sign a contract in addition we have symptom check lists that clarify information needed in order to provide efficient and effective care. Go to .Progress note: The note written each day, or as indicated by patient’s condition, on a patient who is admitted to the hospital or seen in an office. It is important to point out that in progress notes, “timing” becomes particularly important because the timing of events can affect a patient’s medical course and outcome.TEMPLATES, MACROS, AND CLONING(see attached article on templates and micros)There are other shortcuts that may be taken by a healthcare provider to improve efficiency in documentation. These include the use of templates, macros, and cloning, which are outlined below. Shortcuts should be used with caution, as they can lead to over-documentation that may negatively affect the integrity of the patient’s medical record. The only documentation that should be performed is that which justifies the care, treatment, and other services that were provided to that patient.Templates: blank documents that are pre-configured to consist of an outline of a “typical visist”, populated with generic data waiting to be modified to match the current visit. Templates allow for all patient encounters to follow a standardized format, while remaining unique to each patient and condition.Templates save time by having the sections required for the visit outline and ready to accept current information, which can be filled-in with voice-to-text or by free text to make the template patient-specific. Generally, a provider will use multiple templates and select the one matching the type of visit or encounter at hand. For example, a template for an extended visit will have more sections outlined for completion as compared with a template for a briefer visit, which will have fewer sections marked for completion.Macros: Computer shortcuts that have automatically filled-in-data. These are acceptable to use as long as care is taken to modify them to fit the current encounter. Sometimes, the automatic data populated by macros can lead to reporting services not rendered or over documentation, both of which are fraud. Macros allow users to create a lot of text with one keystroke, saving time and effort.Cloning (copy & paste): Copying and pasting previously recorded information from a prior note into a new note. This is a perfectly logical and permissible keyboard shortcut that may be used for specific small bits of information that are relevant to the current visit and do not need to be retyped. An example of appropriate use of cloning: the summary of findings from a recent heart catheterization is copied and pasted (“cloned”) into the note because the finding are relevant o current medical decision making.Anything that is considered as plagiarism is never allowed. We must always identify sources of material rather than take credit for originality. Plagiarism is an easy way to ruin a career, and thus care must be taken regarding information that is cloned. An example of inappropriate use of cloning: a midlevel note is copied and pasted (“cloned”) into the note because their history was complete and accurate. An attending physician is required to perform a separate exam themselves, although less in-depth that if they were seeing the patient on their own and may copy and quote information of other providers.Auto-prompts (drop-down menus, pick lists), macros, templates, and other shortcuts that require selection to be made based on the current situation do not constitute “cloning”. These are legitimate and useful ways to make accurate documentation easier and more efficient.How SOAP Notes Paved the Way for Modern Medical DocumentationInterconnectivity isn’t as new a concept as some health IT vendors let on. Even though EHRs that easily share patient information between providers are revolutionizing health care, the idea of improving inter physician communication has been around for decades. A perfect example? SOAP notes.Today, the SOAP note – an acronym for Subjective, Objective, Assessment and Plan – is the most common method of documentation used by providers to input notes into patients’ medical records. They allow providers to record and share information in a universal, systematic and easy to read format.Many elements of modern health care are a byproduct of the SOAP note. HER systems, a number of HHS’S Meaningful Use objectives, and specialists working off their mobile devices – are all somehow, built upon the SOAP methodology.In fact, SOAP notes are so prevalent among physicians that using an HER equipped with SOAP note template creation is almost unquestionable. The best designed EHRs combine form and narrative based functions to create note taking capabilities that allow you to rapidly drag and drop symptoms as well as input data manually.Today, we look back on the history of the SOAP note and how it can be applied to modern practices.The Story Behind SOAPThe SOAP note was first introduced into medicine by Dr. Lawrence Weed in the 1970’s under the name Problem Oriented Medical Record (POMR). At the time, there was no standardized process for medical documentation.SOAP notes gave physicians structure and a way for practices to communicate with each other, a notion that is still transforming the industry. It was the initial users of SOAP notes who were able to retrieve patient records for a given medical problem fastest – something EHRs do even better today.Similar to how HER software has improved the way providers find patient charts, standardized SOAP notes allowed providers to communicate with each other in clear and concise formats. In their own way, both have significantly enhanced the practice of medicine and improved health outcomes for millions of patients.How to Use SOAP NotesSOAP notes are broken down into the four components mentioned above, and they’re to be followed sequentially in order to complete a patient’s note.Initially, the physician fills out the subjective portion, which includes any information received from the patient, such as history of illnesses, surgical history, current medications, and allergies.Then the doctor moves on to the objective component by entering any vital signs and measurements, findings from physical examinations, abnormalities and results from previous laboratory and diagnostic tests.Next, the assessment is where the doctor diagnosis the patient’s condition according to medical history and objective data provided above.Finally, the plan is where the health care provider will treat the patient’s concerns – such as lab orders, radiological work, referrals, procedures performed, medications given and education provided. This should address each item of the assessment and speak to what was discussed or advised with the patient, as well as scheduling for further review or follow ups.What Does a SOAP Note Look Like?Below is an example of a SOAP note for a patient who has reported head pain after taking a serious fall. Subjective25 yo presents with a head contusion after falling from a horse on to a heavy wooden fence, breaking the fence. Pt complains of primarily head pain, neck pain, right knee pain and some mild coccyx pain. There was a brief loss of consciousness for a short period of time. Pt has been slow to answer questions and has been noted to have repetitive questions since the accident.ObjectivePt in no acute distress. Appears stable with C-collar and rigid backboard HEENT: Minimal tears in the occipital area: pupils: equal and reactive EOMS: FullEARS: no bloodNECK: C-collar in place with a tenderness over the mid C Spine bony are with out obvious swellingCHEST: non- tender to compression. Equal breath sounds.CVA: Regular rhythmABDOMEN: Soft, Non –tender extremitiesNM: Moves all four well. There is mild tenderness on palpitation over the right patellaAssessmentMild concussionPlanCT of the head injury after C-spine is clear. Home with head injury instructions. Recheck with private doctor in 12 days or return here PRN with any change in mental statusFairly straightforward right? Well, simplicity is what Dr. Weed had in mind when he created this quick and efficient way to document patient encounters, which has sequed into the modern medical documentation HER vendor are working hard to perfect. CHAPTER 6: ANATOMY OF A PROVIDER NOTEBelow is a sample template for a generic history and physical (H&P). This chapter will focus on dissecting various parts of a basic note using this template as an outline. Bear in mind that this template is not a universal template. Every institution, individual, specialty, and situation, will likely have a different template based on the specific needs of the provider, medical practice, or patient encounter.Note: The triple asterisks (***) in the template below represent a space meant to be completed by the technician or the medical provider. In the electronic medical record “Epic,” these are known as wildcards. Anything in gray and bracketed by @...@ indicates that this information is automatically imported from elsewhere in the chart. The exact phrase inside of the “@brackets” may vary from institution to institution. Every electronic medical record may handle documentation shortcuts differently. A psychometric technician will need to learn these differences in the electronic medical record at their assigned medical practice. CHIEF COMPLAINT (PSYCHOLOGICAL AND PSYCHIATRIC MENTAL STATUS EXAM REQUIRED) see page 29 and AddendumHistory given by: ***History limited by:***HISTORY OF THE PRESENT ILLNESS (HPI)@NAME@ is a @AGE@ @SEX@ who presents with ***DESCRIPTORS (BILLABLE ELEMENTS)Duration:***Onset:*** / Timing:***Location:*** / Radiation:***Character/Quality:***Intensity:*** / Severity:***Associated Symptoms:***Context:***Modifying factors:*** / Tx before arrival:***REVIEW OF SYSTEMSConstitutional: No fever, chills or recent illness.Eye: No visual changesHENT: No earache or sore throatResp: No dyspnea or coughCardio: No chest pain or palpitations.GI: no abdominal pain, nausea, vomiting, constipation or diarrhea.GU: No dysuria, urgency or frequency.Musculoskeletal/Extremities: No leg pain or swelling. No back pain.Neuro: No headachesSkin: No rashReview of systems is otherwise negative.PAST MEDICAL HISTORY@PMH@FAMILY HISTORY@FAMHX@SOCIAL HISTORY@SOCHX@SURGICAL HISTORY@PSH@MEDICATIONS@PTAMEDLIST@ALLERGIES@ALLERGY@PHYSICAL EXAM is limited based on specialty and medical complaints, preliminary diagnoses and other considerationsVITAL SIGNS: @VITALSIGNS@Constitutional: Well developed. Well nourished. Appearance consistent with BMI of @BMI@HENT: Normocephalic. Atraumatic. Bilateral external ears normal. Nose normal. Moist mucous membranes.Eyes: PERRL, EOMI. Conjunctiva normal. No discharge. No scieral icterus.Lymphatic: No lymphadenopathy noted.Endocrine: No palpable thyromegaly.Neck: Neck is supple. Normal ROM. No stridor.Cardiovascular: Normal heart rate. Normal rhythm. No murmurs, gallops or rubs.Thorax & Lungs: Normal breath sounds. NO respiratory distress. No wheezing.Abdomen: No masses. No pulsatile masses. No distention. No palpable organomegaly. Soft. No tenderness.Genitourinary: No CVA tenderness.Skin: Warm. Dry. No erythema. No rash. Normal capillary refill.Musculoskeletal/Extremities: Good range of motion in all major joints as observed. No major deformitities noted. No extremity tenderness. No edema. No cyanosis. No clubbing.Back: No tenderness.Neurologic: Alert and oriented x3. No focal deficits noted. Normal motor function.Psychiatric: Affect normal, Judgement normal. Mood normal.PROCEDURES***MEDICAL DECISION MAKING (MDM)***PRECHARTING – Nursing home staff should be notified of planned visits and charts requested to be pulled to be ready when providers are expected to arrive. This information should be communicated the night before or morning of visit and a list of patients should be provided to nursing home.Pre-charting is done prior to initiating the current patient encounter agreements with supervisors should be standardized. This entails arriving early prior to provider arriving at nursing station. It is the responsibility to communicate schedule and changes. If this is not SOP then regional manager should be informed and corrective action taken. This also includes reviewing old records for additional information, and populating a new note with prior elements that may be relevant to the current visit. Pre-charting can be automated (for example, SmartLinks in some electronic health records automatically pull forward relevant information) or it can become a scribe function. It is more likely to be some combination of the two.Relevant elements from the patient’s medical record could include results of tests or procedures performed; other provider or consultant evaluations and recommendations; an updated medication and allergy list; previously documented medical, surgical, familial, and social history; and anything else that may have happened to the patient medically since their last visit.CHIEF COMPLAINTThe chief complaint is a short description of a patient’s symptom(s), problem, condition, or diagnosis. The nursing home staff should complete a referral form, if not it should be completed prior to seeing patients in order to be efficient and effective. If this is a problem, the supervisor and regional manager should discuss this with nursing home management teams in order to provide high quality care and documentation. This is the reason for the patient’s visit, generally in their own words. The chief complaint is typically first recorded by the triage nurse prior to bringing the patient back to a room in the emergency department. Most emergency departments will give a score to each patient, known as their acuity level, based on the triage nurse’s assessment of the severity of illness or intensity of services felt to be required. The acuity system informs the provider which patients need to be seen more urgently than others. This decision is not based entirely upon which patient arrived first to the department. Note: The severity score given to each patient by the triage nurse is not to be confused with the billing severity scoring (better termed the “Intensity of service”). Determining the level of service for billing depends largely upon the documentation that is created by the provider. The Mental Status examination should also be given.This is the primary type of examination used in psychiatry. Though psychiatrists do not use many of the more intrusive physical examination techniques (such palpation, auscultation, etc.), psychiatrists are expected to be expert observers, both of significant positive and negative findings on examinations. This observation should take place throughout the patient encounter; it is not limited to any one point. However, the observations are then recorded into a specific structured format that is labeled the Mental Status Examination (MSE). When properly done, the MSE should give a detailed "snapshot" of the patient as he presented during the interview. Often beginners become confused about the difference between this and other parts of the history. A simple way to keep it apart is to remember that this is, as the title says, an examination, therefore it should be limited to what is observed. The rest should go in the history. As an example, if a patient reports that they have been hearing voices throughout the day, but deny hearing them during the interview and do not seem to be responding to internal stimuli, one would not report the hallucinations as part of the MSE, but rather include it earlier in the history. Conversely, if the patient denies any history of hallucination, but seems to be responding to internal stimuli throughout the examination, one would report the phenomenon on the MSE. The MSE can be divided into the following major categories: (1) General Appearance, (2) Emotions, (3) Thoughts, (4) Cognition, (5) Judgment and Insight. These are described in more detail in the following sections. General DescriptionAs implied, this is a general description of the patient’s appearance. Being detailed and accurate is important, and such observations can be of great use to the next examiner. Imagine, for example, if a patient presents looking disheveled, poorly groomed with poor hygiene to an emergency department, but a note from only a month ago reports the same patient to have been well dressed and groomed. Something is going on!Some of the areas that might be commented on, particularly if they have significant negative or positive findings include:AppearanceOne should describe the prominent physical features of an individual. At least one writer on the subject has suggested this should be detailed enough "such that a portrait of the person could be painted that highlights his or her unique aspects” but that is probably asking a lot. Some aspects of appearance once might note include a description of a patient’s facial features, general grooming, hair color texture or styling, and grooming, skin texture, scar formation, tattoos, body shape, height and weight, cleanliness and neatness, posture and bearing, clothing (type, appropriateness) or jewelry.Motor BehaviorThe examination should incorporate any observation of movement or behavior.Some aspects of motor behavior that might be commented on include gait, freedom of movement, firmness and strength of handshake, any involuntary or abnormal movements, tremors, tics, mannerisms, lip smacking or akathisiasSpeechThis in not an evaluation of language or thought (save that for later), but a behavioral/mechanical evaluation of speech. Items that might be commented on include the rate of speech, the spontaneity of verbalizations, the range of voice intonation patterns, the volume of speech, and any defects with verbalizations (stammering or stuttering). AttitudesOne should comment on how the patient related to the examiner. This usually includes a discussion of the patient’s degree of cooperativeness with the examiner. When appropriate, a recording of the evaluator’s attitude toward the patient might be appropriate, as we believe such reactions (“countertransference”) may be useful information. Such discussions should be done with the understanding that the patient has a legal right to read the record, and any strong emotions or reactions should be recorded in a diplomatic manner. Emotions For the sake of consistency, the observation of a patient’s emotions is divided into a discussion of mood and affect.Mood is usually defined as the sustained feeling tone that prevails over time for a patient. At times, the patient will be able to describe their mood. Otherwise, evaluator must inquire about a patient’s mood, or infer it from the rest of the interview. Qualities of mood that may be commented on include the depth of the mood, the length of time that it prevails, and the degree of fluctuation. Common words used to describe a mood include the following: Anxious, panicky, terrified, sad, depressed, angry, enraged, euphoric, and guilty. Once should be as specific as possible in describing a mood, and vague terms such as “upset” or “agitated” should be avoided. Affect is usually defined as the behavioral/observable manifestation of mood. Some aspects of a mood that we might comment on include the following: the appropriateness of the affect to the described mood (does the person look the way they say they feel?); the intensity of the affect during the examination (is their too much--heightened or dramatic--or too little blunted or flat); the mobility of the affect (does the affect change at an appropriate rate, or does there seem to be too much variation–a labile affect-- or too little--constricted or fixed; the range of the affect (is there an expected range of affect–usually interview will have light and heavier moments–or does the affect seem restricted to a limited range; and the reactivity of the patient (is the response to external factors, and topics as would be expected for the situation. Alternatively, is there too little change--nonreactive or nonresponsive?). Thought Usually, a description of a patient’s thoughts during the interview is subdivided into (at least) 2 categories: a description of the patient’s thought process, and the content of their thoughts. Thought process describes the manner of organization and formulation of thought. Coherent thought is clear, easy to follow, and logical. A disorder of thinking tends to impair this coherence, and any disorder of thinking that affects language, communication or the content of thought is termed a formal thought disorder. Some aspects of thought process that are usually commented on include the stream of thought and the goal directedness of a thought. A discussion of the stream of thought might include a discussion of the quantity of thought: does there seem to be a paucitThe acuity system is as follows:ESI 1 – Requires immediate lifesaving provider intervention, often including resuscitation of some type. Examples include cardiac arrest, severe bleeding, acute stroke, or myocardial infarction.ESI 2 – High risk of deterioration requiring emergent evaluation, often indicating that the patient is confused, has severe pain or has abnormal vital signs. Examples might be a severe asthma attack or seizure. ESI 3 – Stable patients who require attention urgently, as they ha ve complaints that likely need multiple resources for evaluation (like labs and imaging) and could indicate a serious medical problem. Examples may include abdominal pain or COPD with a fever and a cough. ESI 4- Patients who are stable and less urgently need to be seen, requiring only a single resource type to treat or evaluate. Some examples may be a simple laceration or an ankle sprain.ESI 5 – These are non-urgent patients with no resources required for their care. Examples include a simple rash or prescription refill. @NAME@ is a @AGW@ @SEX@ who presents with (chief complaint).HISTORY OF THE PRESENT ILLNESS (HPI)The history of the present illness (HPI) is a coherent story, usually chronologic, describing the patient’s present illness from the first sign or symptom to the present. The history is the heart of the document and is usually the primary portion of the patient note where the scribe’s work takes place. Creating the history entails 1)listening to the history provider, which may be the patient themselves, a family member, a care provider, or someone else such as EMS personnel; 2) shorting through the information gathered; and 3) creating an accurate and coherent story. The history should never be pulled from a prior encounter and should be specific to the current visit. The rest of this chapter will review the remaining element of an ED provider note. Chapter 6 “Synthesizing a History, “will examine the history the present illness in further detail. DESCRIPTORS (BILLABLE ELEMENTS) See DSM-V and see CPT procedural manual in Resource Manual.Descriptors, also known as billable elements, are pertinent aspects of the history that are counted and used to determine the history’s highest billable level. In total, there are 12 descriptors, but only 8 billable elements. This is because, in some cases, more than one descriptor contributes to one billable element. For example: “onset” and “timing” are both descriptors, but count towards one billable element. One or both can be documented but only one billable element will be achieved. Per the SPC policy codes, as determined by law, the HPI can be billed to different levels depending on the number of billable elements present in the history. Low complexity (brief) visit – 1 (or more) of 8 billable elementsHigh complexity (extended) visit – 4 (or more) of 8 billable elementsNumber of elements to obtain: Ultimately, the number of billable elements in the history is considered when calculating the entire chart’s highest billable level. As a scribe, you will not know how your provider (or their representative, such as a billing and coding specialist) will choose to bill the patient for their visit at the end of the encounter. To ensure that the chart can be billed at the highest level your provider deems appropriate and the document substantiates, it is best that you try to document enough billable elements to support the highest billable level. Thus, the recommendation is to include at least 4 of 8 billable elements in the history.Meeting the billing requirement: If there are not enough billable elements to meet the minimum requirement to bill for the highest complexity visit in a complex case, you should ask the provider to obtain additional billable elements from the historians. Your provider will be happy to do this so they can be paid for the visit. Remember, a scribe should be a partner in documentation for the provider!Limitations to history: If the history is limited (for any reason) and thus enough billable elements cannot be obtained, the requirement for billing will be forgiven as long as there is documentation describing the limitation. Using the billable elements template: For ease of documentation, a template may be created to allow for faster and more accurate charting. An example of such a template is seen above in the sample note. Initially, all billable elements should be documented as a part of the main body of the history. As mentioned above, they each describe a different aspect of the history. After the history is written, the billable elements template should be completed using the information in the history. To u se the template properly, you must:Place each billable element in the proper section. Each billable element describes a specific aspect of the history and information cannot be interchanged between sections.Delete any billable elements that were not discussed. Completing missing information your self is falsification and is unacceptable. Elements that were not discussed should be removed from the template. Note: Pertinent negatives, which encompass information pertinent to the patient’s course of treatment that is “denied” (e.g. a history of diabetes, smoking history, any symptoms, etc.) should be retained within the history and the billable elements. “Negatives “are equally important as “positives.”In the sample template provided, descriptors placed next to one another count as “one” billable element (e.g. “onset” and “timing”).Billable elements descriptions: The following are the billable elements with a description of what each entails. Below some of the elements, frequently encountered examples are also listed. This is by no means a comprehensive list. However, it can be used as a reference.Note: The billable elements are numbered 1-8. Descriptors with letters (e.g. “1a” and “1b”) count as one billable element.Duration: Length of time the chief complaint has been present. *This is necessary to document the length of time required to comply with reimbursements and CMS guidelines.Examples: Hours, days, weeks, months, year, since childhood, etc.2aOnset: Describes how the chief complaint began (in terms of time).Examples: abrupt, sudden, gradual2bTiming: Frequency that the chief complaint occurs. Multiple descriptors for “timing” can be used together (e.g. pain is constant and worsening).Examples: constant, intermittent, episodic, chronic, persistent, waxing and waning, worsening, improving, resolving, ongoing, consistent, chronic, etc.3aLocation: Where the patient locates the chief complaint. This is mostly applicable to pain or other sensory changes (like paresthesia, or the sensation of “pins and needles”). You should not try to use a “systems based” approach to complete this element. For example, if a patient presents with shortness of breath, “respiratory” is not the location. Shortness of breath can be caused by many things: it could be cardiac-related (such as with myocardial infarction, also known as a heart attack) or it can be a symptom of allergic reactions. Thus it would be inaccurate to try and pinpoint the etiology, or cause, of a chief complaint or symptom based on history alone.3bRadiation: Extension of a sensation or pain from the origin to another region. Noted: If “location” is not used in your history, then “radiation” will not be used either, by definition.4Character/Nature: Subjective description of how something feels to the patient. Typically, single adjectives are used here (listed below). However, some things cannot be described with an adjective. In those cases you may put what the patient said in quotations, (e.g. “the pain feels like being stabbed by a thousand samurai swords”).Examples: throbbing, aching, cramping, sharp, dull, stabbing, squeezing, pressure, etc.5aIntensity: Subjective description of pain on a numerical scale rated 1 through 10, where “1” describes the least amount of pain, and “10” describes the most. Sometimes a patient will rate their pain more than once, such as before and after receiving medications, or with waxing and waning pain. In these cases you must document each pain rating and what even precipitated the fluctuation.5bSeverity: Subjective description of pain on a graded scale comparing mild, moderate, and severe.6Associated symptoms: All acute “positive” symptoms that the patient is experiencing other than the chief complaint. Although both “positive” and “negative” symptoms should be documented in your history, only positive symptoms should be documented in the billable elements template in the “associated symptoms” section. Positive symptoms can include: 1) any symptom that accompanies the chief complaint, also known as “true” associated symptoms; and 2) miscellaneous positive symptoms elicited while discussing review of systems (discussed later), that the patient may believe are related to the chief complaint.7Context: Any circumstances surrounding the present illness. This may include what the patient was doing or where they were during symptom onset or it can include exposures or activities at the time the symptoms began.8aModifying factors: Any alleviating or aggravating factors, which are things that make symptoms or signs better or worse. These are typically discovered incidentally and include specifics such as certain movements, positional changes, or eating or drinking.………………………………………………………………………………………………………………………………………………………8bTreatment before arrival: This refers to any attempts at alleviating a symptom by the patient prior to evaluation. This is typically done intentionally, with the goal of alleviating discomforts. Examples include medications (prescribed or not prescribed), apply ice, heat, pressure, or bandages, or alternative medicines (e.g. acupuncture or herbal supplements). The second aspect of “treatment before arrival” that must be documented is whether or not the treatment provided any relief or benefit. Examples of this include full or partial relief, transient or temporary relief, or not relief achieved. 4 REVIEW OF SYSTEMS (ROS)Review of systems (ROS) is a systematic listing of all symptoms, organized by system that may or may not be associated with the chief complaint. Symptoms are things that patient experiences and are thus considered subjective. Symptoms are considered to be either present or absent. Present symptoms are designated as “positive” or “+” or “affirms”. Negative symptoms are designated as “negative” or “-“or “denies.” Some symptoms can be appropriately placed into multiple systems, but should only be reflected n the review of systems once. Some electronic medical records may place positive finding in red or bold text. This is not required, but does help the reader to more rapidly identify the pertinent positive findings. The review of systems must be documented for the current encounter, and, if pulled from a prior visit, must be adjusted to reflect the current visit. If no changes are made to the copied review of systems, then comment must be made specifically stating that there is no change from the prior visit.In the health clinic, if the provider asks “are there any other symptoms?,” or something this effect, this is considered as giving the patient opportunity to disclose any other pertinent information. In this case, you may document the following below the review of systems”Review of systems was reviewed and is otherwise negative.”Billing review of systems: Per the health clinic codes, as determined by law, the review of systems can be billed at five different levels depending on the number of systems that are present. To be documented on progress notes and necessary for payment of services rendered:Very low complexity visit – 0 systems in ROSLow complexity (“Problem Pertinent”) visit – 1 systems in ROSModerate complexity visit – 1 systems in ROSModerate complexity but more urgent (“Extended”) visit – 2-9 systems in ROSHigh complexity visit (“Complete”) – 10 or more systems in ROSNumber of elements to obtain: Ultimately, the number of systems in review of systems is considered when calculating the entire chart’s highest billable level. As a scribe, you will not know how your provider or their representative (such as billing and coding specialist) will choose to bill the patient for their visit at the end of the encounter. To ensure that the chart can be billed at the highest level your provider deems appropriate, it is best to try to document as many elements as appear relevant. However, over-documentation is not necessarily the best solution. For example, documenting 10 systems in review of systems for level 4 acuity (perhaps something like a minor finger injury) is excessive and unnecessary.Thus, the recommendation is the following: If an encounter is lower acuity (such as a four or five), it is acceptable to aim for 2-9 systems. If an encounter is higher acuity (such as a one, two, or three), it is preferable to aim for 10 systems. Be aware that the patient’s acuity level may change throughout their visit based upon what is elicited during the history and physical exam. Meeting the billing requirement: If not enough systems were included in the history in order to meet the minimum requirement to bill for the highest complexity, you should ask the provider to obtain additional symptoms from the historians. Your provider will be happy to do this so they can be paid appropriately for the visit. A scribe should be the provider’s partner in documentation.Limitations to history: If the history is limited for any reason and thus enough systems cannot be obtained for billing purposes, the requirement will be forgiven as long as there is documentation describing the limitation. This should be reflected after the review of systems in the form of the following statement (or a statement with a similar effect):Review of systems is otherwise limited due to _______.Using the review of systems template and template for Mental Status Exam: For ease of documentation, a template may be created to allow for faster and more accurate charting. An example of such a template is seen above in the sample note. This template documents a completely negative review of systems. Initially, all symptoms should be documented in the main body of the history. After the history is written, the review of systems template should be completed using the information documented found in the history. To use the template properly, you must:Add symptoms that are present (“positive” or “=” or “affirms”) and add symptoms that are absent (“negative” or “-“or “denies”). Although this template makes documentation faster and easier, it is by no means comprehensive. If symptoms are discussed that are not included in the template, be sure to add them and note if they are present or absent.Remove contradicting statements. Notice that this template documents a completely negative review of systems. If you note “positive abdominal pain” in the “GI” system, you must remember to remove “no abdominal pain” from the template. IF not removed, this will become a contradicting statement with abdominal pain documented as simultaneously present and absent.Remove symptoms or organ systems that were not discussed. It is pertinent to delete symptoms or systems that were not discussed. Leaving these in the template is falsification of information and is unacceptable.ADDITIONAL HISTORYAdditional History: The history of the present illness can also contain additional history felt to be relevant to the chief complaint. This includes past medical history, family history, social history, surgical history, the patient’s current medication list, and a list of known allergies. This information can be found elsewhere in the chart and is thus not required to be reiterated in the history. However, if additional history is discussed by the provider and the patient, it should also be documented in the history because the information likely pertains to the present illness. For example, a patient on many medication recently started a new medication is experiencing new symptoms. Since these new symptoms may be related to the new mediation, the medication change should be a part of the history and not just listed under “Medications” elsewhere in the chart. This is also an example that illustrates how both positive and pertinent negatives may be relevant to the current problem.The elements of additional history may be pulled from prior encounters, but must be updated to reflect current realities. A scribe may update these elements: however, they must be specifically told to do so by the provider. Otherwise the provider, or other ancillary staff like nursing or medial assistants, should make updates if needed. Finally, the provider must review the elements imported into their note and mark them as reviewed before the note can be completed and signed.Billing additional history: These are not required in the history and there are no emergency department codes, as determined by law.5PAST MEDICAL HISTORY (PMHx)Past Medical History (PMHx): This refers to all formally documented and verbally relayed medical history. This can include illnesses, injuries, and treatments. It is often obtained by the nurse or brought forward from prior visits. New elements discovered during the current visit may need to be added. 6FAMILY HISTORY (FHx)Family History (FHx): This refers to any major disease that runs in a patient’s family. Only blood relatives should be considered. This is often used to assess a patient’s risk for certain diseases. 7SOCIAL HISTORY (SHx)Social History (SHx): Any social behaviors that may contribute to human health and disease. This includes substance use, occupation, and lifestyle.Substance use: Implies the use of any substance (other than medication) that is used to achieve a sensory change. Substances may include tobacco, alcohol, and illicit drugs. Types and quantity of substances may be pertinent to clinical decision making and, thus, should be documented. Former substance abuse, the time since last use, and duration of use, should also be noted. These factors can contribute to addiction and tolerance levels. Tobacco can be taken orally (known as “dip” or “chew”), or smoked with pipes, cigars or cigarillos, or cigarettes. Counting “pack-years” is used to quantify an individual’s degree of tobacco exposure. This is calculated by multiplying the number of packs a person smokes per day, by the number of years they have smoked. For example, if a patient has smoked one pack of cigarettes a day for thirty years, they have a 30 pack-year history. Alcohol is typically ingested orally. Patients may use alcohol never, rarely, occasionally, or socially. Some may use a certain number of days a week. Others may use every day. Because different drinks vary in alcohol content, be sure to document the type of drink, amount, and number of drinks during a period of time. This becomes especially important for individuals seen for acute alcohol intoxication, or possible alcohol related withdrawal.Illicit drugs: Any drug that is illegal to make, sell, transport, or use. These can be snorted, injected, smoked, or ingested orally. This method of intake can pose potential problems or complications, aside from the pharmacologic properties of the drugs. For example, intravenous injection can result in endocarditis (inflammation/infection of the endocardium of the heart) or epidural abscesses (pockets of infection in the space around the spinal cord). Snorting a drug repeatedly can erode the nasal septum (cartilage that separates the left and right nares). The most common illicit drugs include cannabis (marijuana or hashish), amphetamines, cocaine or crack cocaine (typically the former is injected or snorted, while the latter is smoke) MDMA (known as ecstasy or molly or XTC), and mushrooms (known as magic mushrooms). Opiates and opioids are becoming an area of interest as they continue to grow in popularity. Some, like hydrocodone, hydromorphone, oxycodone, fentanyl, and morphine, are given in the hospital and as prescriptions to treat pain. Conversely, heroin is an opioid with no accepted medical uses and is thus classified as an illicit drug. Opioids have high addiction potential and healthcare professional are now seeing a lot of drug-seeking behavior as a result. This means that people are returning to their doctor or coming to the emergency department specifically asking for opioid pain medication. There are also a rising number of opioid-related drug overdoses, particularly from heroin. In these circumstances you may hear of a drug called Narcan (naloxone), which reverses the effect of opioids.Occupation: Plays a significant role in human health and morbidity and/or mortality. Different occupations can put an individual at higher risk for certain medical condition, injuries, or death. For example black lung disease (also called coal worker’s pneumoconiosis) commonly afflicts laborers in coal mines due to prolonged and excessive inhalation of fine coal dust particles. More commonly seen, occupations with a heavy workload (lots of heavy lifting and straining) may result in more musculoskeletal injuries. Sedentary jobs that involve a lot sitting may be a risk factor for cardiovascular disease (more below).Lifestyle: Also contributes to the human health and morbidity/mortality by altering a person’s risk for certain medical conditions or diseases. This can include sexual orientation, exposure to certain environments (e.g. time spent in jail or a nursing home), socioeconomic status and living situation, dietary choices, and activity level. For example, a “sedentary lifestyle,” or a combination of inadequate exercise and poor diet, can classify as a risk factor for cardiovascular disease.8PAST SURGICAL HISTORY (PSHx)Surgical History (PSHx): Any past procedures or surgeries. It is important to document the type of surgery or procedure, the date it was performed, the name of the surgeon, if there were any complications perioperatively, and the hospital where the surgery took place.9MEDICATIONS (see Nursing Home computerized and comprehensive list of medications)Medications are either given “in-house” (on site) or as prescriptions for the patient to take home. A scribe will have to record the names of many medications during documentation. This could include prescribed medications used to treat known disease, over the counter medications, and even medications prescribed to someone else that the patient is taking. In addition to recording the medication name, the scribe should record the dose, form of the drug, and the frequency that the medication is taken or used. This information will likely play a role in the provider’s medical decision making. For example, knowing medication dosages is important because too much medication may harm a patient. A provider may need to give a patient their daily mediations during their emergency department visit, but should give them the amount that they are currently prescribed to avoid any complications.Alternative medical supplements are a unique area of interest. There is controversy surrounding the ingredients and possible contraindications (reasons why something isn’t recommended). Many alternative medicines are unregulated and can have unknown ingredients.Naming drugs: Every drug has a chemical name, a generic name, and one or more trade names. The chemical or scientific name is based on the chemical structure. The trade name (also called the brand name or trademarked name), is typically a patented drug formulation. One drug can have several manufacturers, each with a different brand name. Brand names always begin with a capital letter. The non-proprietary name (also called the generic name), are drugs with the same drug formulation of a brand name sold at a more affordable cost. Generic names always begin with a lowercase letter.Using the brand versus generic name: If you are recording what medications a patient is taking, it is always best to be as specific as possible. For example, if the patient is taking the “Lipitor” brand of “atorvastatin”, “Lipitor” is recorded. If unknown, the generic should be used. In actuality, a scribe does not usually have the knowledge to make this determination. Therefore, the scribe should record what the provider, nurse or other medical personnel has recorded.Additional naming conventions: In addition to the different names of drugs, there are also naming conventions that implicate different meanings. Intercapping is the capitalization of letters within a drug name. This is sometimes used by companies to make their product distinct. For example, “MiraLAX” where “LAX” tells the consumer that the drug is a laxative. Tall-man letters are a safety precaution in the electronic medical record used to distinguish between similar sounding drugs. For example, these letters are used to highlight the difference between “prednisone” and “prednisolone.” The scribe need note include these “tall-man letters” in the chart. Rather, the scribe should take precautions to document the correct drug and not similar sounding one. Writing for medications: A technician may be involved in ordering a medication in the electronic medical record or help to write a prescription reviewing the BIERS criteria. However, a technician does neither of these things without being told to do so by a provider. The consent obtained on admission and beginning and initiation of psychotropic (addendum informed consent). It is only valid if the patient does not have cognitive problems which interferes with their ability to give consent unless they have given power of attorney. It should be realized that an individual may be competent in some areas but not others thus it is not all or none (see SPC CME on Decision Making). This is a legal There are certain safeguards in place in the electronic medical record that allows the scribe to enter medications an prescription into the record. These include “hard-stops” after a scribe places orders or creates prescription. The scribe may “pend”, or save their work, but the hard-stops prevent the order or prescription form being acted upon unless the provider has reviewed, approved, and signed the scribe’s work. In addition to the hard-stops, the electronic medical record should send notifications to the provider (such as medication contraindications, which includes as allergies and drug-drug interactions), even if they were sent to the technician first. 10ALLERGIESAllergies may include true allergies, intolerances, or contraindications. Many people have allergies to medications, foods, or exposure to different environmental triggers. This occurs when the immune system becomes hypersensitive to an innocuous antigen (protein) and reacts as if the antigen is pathogenic. Intolerance differs from an allergy because the symptomatology is not consistent with “true” allergic reactions. Symptoms could include known drug side effects. A contraindication is an absolute reason why a a certain line of treatment shouldn’t be utilized. This could include interactions with other medications or medical conditions in which it is unfavorable to give certain medication. For example, the use of NSAIDs (non-steroidal anti-inflammatory drugs) in a patient who has renal disease.Reactions range from mild to severe and can include a myriad of symptoms depending on the severity of the reaction, the amount of allergen exposure, and route of contact with the body. Symptoms may include uticaria (hives), pruritus (itching), erythema (redness), angioedema (swelling) of the face or palms/soles of the hands and feet, shortness of breath, nausea, vomiting, diarrhea, and many more.11PHYSICAL EXAM the extent and comprehension is determined by specialty and the medical problems, diagnoses and treatment plan. All patients must have a physical exam by a PCP in the first 10 days and every 90 days after.Physical Exam (PE) is a list of signs, organized by system, that are elicited by the provider as they are examining the patient. Signs are things that a provider finds or observes, and are, therefore, objective. Signs should be designated as present or absent. Some signs can fit within multiple systems, but should only be reflected in the physical exam once.The physical exam is typically performed after the history has been collected and may involve one or more organ systems. The extent of the exam and what was examined will depend upon what was elicited during history and review of systems. Thus, the physical exam can be problem-focused or comprehensive. The physical exam should never be pulled from a prior encounter and should be specific to the current visit.Billing physical exam: Per the emergency department codes, as determined by law, the physical exam can be billed at five different levels, depending on the number of systems that area documented:Straightforward complexity visit – 1 systems in physical examLow complexity visit – 2-4 systems in physical examModerate complexity visit –2-4 systems in physical examModerate complexity but more urgent visit – 5-7 systems in physical examHigh complexity visit – 8 or more systems in physical examNumber of elements to obtain: Ultimately, the number of systems in the physical exam is considered when calculating the entire chart’s highest billable level. As a scribe, you will not know how the provider or their representative (such as billing and coding specialist,) will choose to bill the patient for their visit at the end of the encounter. To ensure that the chart can be billed at the highest level your provider deems appropriate, it is best that you try and document as many elements as appear relevant. However, over documentation is not necessarily the best solution. For example, documenting an 8 system physical exam for level 4 acuity (perhaps something like a minor finger injury) is excessive and unnecessary.Thus the recommendation is the following: if an encounter is very low acuity (such as a five), then it is acceptable to aim for 1 system in the exam. If an encounter is low acuity (like a four), then 2-4 systems should be documented. If an encounter is higher acuity (such as a three, two, or one), it is preferable to aim for 8 systems. Be aware that the patient’s acuity level may change throughout their visit based upon what is elicited during history and exam. If this is the case, be sure that the billable level of the physical exam changes to match this.Meeting the billing requirement: If there are not enough documented systems to meet the minimum requirement for billing for the highest appropriate level of complexity, you should ask the provider to obtain additional physical exam elements from the patient. Your provider will be happy to do this so they can be paid adequately for the visit. Remember, a scribe should be a partner in documentation for the provider (discuss with the provider that this is a contractual requirement for employment).Using the physical exam template: For ease of documentation, a template may be created to allow for faster and more accurate charting. An example of such a template is seen above in the sample note. This template documents a completely normal physical exam. To use the template properly, you must:Add signs that are present and add signs that are absent. Although this template makes documentation faster and easier, it is by no means comprehensive. If elements of a physical exam are performed, but are not included in this template, be sure to document them in addition to the elements found in the given template.Remove contradicting statements. Notice that the sample template documents a completely normal physical exam. If you note “epigastric abdominal tenderness” in the “GI” system, you must remember to remove “no abdominal tenderness” form the template. If not removed this will become a contradicting statement, with “abdominal tenderness” documented as simultaneously present and absent.Remove symptoms or organ systems that were not discussed. It is pertinent to delete parts of exams or entire systems that were not examined. Leaving these in the template is falsification of information and is unacceptable.Observable elements: There are portions of the physical exam included in the template that can typically remain in the documentation unless otherwise abnormal. These are things that may be observed about a patient by carefully watching them move and listening to them speak. However, for briefer visits requiring only 1 system or 2-4 systems in physical exam, including all of the observable elements in the exam may be considered over-documentation. The provider will usually say how many systems they would like to include for a briefer visit with an acuity lvel of four or five. For example, a finger injury needs to include only a finger exam. For more complex visits with an acuity level of three, two, or one, these elements should be retained in the exam. Others systems that the provider chooses to examine should be added to the exam, in addition to the observable elements. Commonly utilized observable elements include the following; Constitutional: Well developed. Well nourished. HENT: Normocephalic. Atraumatic. Bilateral external ears normal. Nose normal. Moist mucous membranes.Eyes: PERRL, EOMI. Conjunctiva normal. No discharge. No scieral icterus.Neck: Neck is supple. Normal ROM. No stridor.Thorax & Lungs: No respiratory distress. No wheezing.Musculoskeletal/Extremities: Good range of motion in all major joints as observed. No major deformities noted. No extremity tenderness. No edema. No cyanosis. No clubbing.Neurologic: Alert and oriented x3. No focal deficits noted. Normal motor function.Psychiatric: Affect normal, Judgement normal. Mood normal.Vital Signs: These are taken by the triage nurse and other nurses throughout the patient’s stay, and are recorded in the medical record. These may then be automatically imported into the note by the EMR template, if set up to dos os. IF the provider takes the patient’s vital signs during their evaluation, the scribe may document these in the record,as well, in the physical exam or elsewhere in the chart.12 PROCEDURE NOTESElements of a procedure note: Certain elements of a procedure should be documented in the note in order to properly bill. Generally, many procedures include the majority of the elements below, but the content of each element will vary based on the procedure. Name of procedure: Self explanatoryIndication for procedure: Reason why the procdure is being done. For example, the indication for a chest tube could be pneumothorax (collapsed lung).Consent obtained on admission and beginning of initiation of psychotropic (see addendum informed consent): This section documents that the patient, or other consenting party if the patient is unable, agreed to have the procedure performed. It is important to document informed consent, where the provider gives the patient adequate information about the procedure including risks and benefits, and allows the patient to make an informed decision regarding having the procedure performed. Exceptions to informed consent include the unconscious patient, the patient who is not competent enough to make a rational decision, and the minor (less than 18 years of) who requires emergent care in the absence of an adult representative. On the other hand, implied consent comes into play for minor procedures such as a laceration for which the patient has sought treatment. Implied consent does not require signed documentation by the patient giving permission to repair the wound. 13 MEDICAL DECISION MAKING (MDM) (See SPC training CMEs information)*see DSM-V on treatment planningMedical decision making (MDM) is the provider’s domain to document their evolving thought processes during the patient’s visit. This would include things like the differential (a list of possible diagnoses or impressions), consults that were made on behalf of the patient (e.g. cardiology, crisis, home health, etc.), tests ordered and the interpretation of results, and any final conclusions or impressions with a plan of treatment. Medical decision making is ultimately categorized as one of the following complexities by the provider: straightforward, low complexity, moderate complexity, or high complexity. The complexity of the encounter is determined by a combination of factors, including the extent of the work-u[ and the history required to ascertain a diagnosis and frequency of visits for various members of a team that is dictated by the attending psychiatrist or protocols.A technician generally does not document in this part of the chart, but can add things if a provider explicitly asks. Examples could include consults with other healthcare providers including timestamps and plan of treatment, or re-checks on patients with the provider’s comments thoughts or findings. A technician may also type in the medical decision making for a provider who is dictating to them, if they are working with a provider who is not proficient or is uncomfortable using electronic medical records. If a comprehensive note is not put in the chart immediately, a handwritten note should be placed in the medical record noting this and identify important information that other professionals may need to make better decisions.CHAPTER 7: SYNTHESIZING A HISTORYNow that we have dissected an ED provider note and have discussed each element in detail, let’s begin building a history from all of this information, one block at a time.HISTORIANS AND LIMITATIONSHistory given by: History may be provided by many sources but primarily by the psychiatric referral form. It is important to document “who” is saying “what.” This may indicate the reliability of the history. The historian is noted at the very top of the sample chart given in the previous chapter. If a patient does not speak or understand the English language a translator should be provided by the nursing home. It is important to have the referral form to obtain input from nursing home staff and referring physician. Target symptoms to develop treatment plan.Examples: the patient, paramedics, police, nurses, caretakers, family, etc.Once the history provider is designated, it is assumed that the same speaker is providing the history unless otherwise noted. It is unnecessary to say: “the patient says…the patient states…the patient report.” This becomes redundant and difficult to read. IF the reported history comes from different sources, then this distinction must be made as the history progresses.History limited by: Meant to account for any factors that may compromise the reliability of the history. This is noted at the very top of the sample chart given in the previous chapter. You are to make a note when the referral form is complete.Examples: dementia, unconscious and/or unresponsive, intoxication, emergent nature, poor historian, language barriers, less knowledgeable history providers, et.Limiting factors are especially important to document in order to achieve “forgiveness” for billing requirements of the billable elements and review of systems.LANGUAGEThe language of an HPI should be objective, rather than subjective. Tone, or how the writing sounds to the reader, is equally as important as organization, accuracy, and content. Tone can be adjusted by word choice. Using objective terminology will make documentation sound professional, whereas subjective terminology will create a negative connotation directed at the history provider. If a patient speaks a foreign language a translator should be obtained and the nursing home is required to make arrangements. If one has this information prior to the visit, the charge nurse or DOM should be informed of the needs.Speaking verbs: The first verbs required when constructing a history are speaking verbs. These denote that the historian is actively saying something, and should be writtenin the present tense.Examples of objective speaking verbs: The historian…state, reports, indicates, describes, associates, affirms, denies, etc.Example of subjective speaking verbs: The historian…feels, complains, whines, etc.It is a good rule of thumb to start the first sentence of the history with the type of historian followed by a speaking verb. “States” or “reports” are the preferred choices. This ensures that a historian is designated, and an appropriate, objective is used verb to begin the history.Example: “The patient (or other historian) states/reports…”The other examples of speaking verbs can be used in different circumstances. Some patients, like some elderly patients or small children, cannot speak, but they can “indicate: that they are in discomfort or distress. When reporting nature/quality of a sign or symptom, “describes” can be used. Sometimes a patient will relate their current sign or symptom to a prior episode, or will believe they have identified an inciting factor. In these cases k, it can be said that they are “associating’ their symptoms. “Affirms” or “denies” may be used when noting positive or negative findings. A concise summary of these alternative circumstances when using speaking verbs are below:Nonverbal patients or small children: “The patient indicates…”Reporting nature/quality or a sign/symptom: “The patient describes…”Identifying inciting factors/prior episodes: “The patient associates…” Reviewing ROS: The patient “affirms” or “denies”…Action verbs: The second verbs required to write a history are action verbs. These denote that something is happening to an historian usually the development of signs or symptoms. These can be written in many tenses, though typically they are used to describe past events. Examples of objective action verbs: developed, began to experience, had, etc.Action verbs should be used after the historian has been designated and the speaking verb has been chosen.Example: “The patient (or other historian) states/reports that they developed/began to experience/have had…”Medical terminology should be used whenever possible in lieu of the equivalent layman’s term. Although the scribe will not be eliciting information from a patient, as a spart of the health care team it is prudent to consider a patient’s level of education. If the patient is unfamiliar with medical terminology, they may describe their medical history in a manner that is familiar to them. It is the scribe’s duty to take this information and translate it into medical speak. For example, if a p patient says that they had their gallbladder removed, the scribe should document “surgical history includes a cholecystectomy, “or something of the like. BUILDING BLOCKSNow that you are familiar with the language that should be used in constructing a history, let’s move our attention to the heart of the content: the billable elements. Many of the billable elements are routinely asked by the provider in order to narrow down a differential diagnosis, or a list of possible diagnoses, given the patient’s history and what is elicited during the physical exam. However, not all billable elements will be discussed, nor are they required for billing. Remember, the recommendation is to aim for 4 of the 8 elements in order to bill for a level five complexity, if needed.Reviewing the billable elements template, notice that many of the elements are ordered in a way that would make sense if telling a story (the history). For the sake of simplicity, below is a generic version of a short templated history including only the billable elements.TEMPLATED HISTORY: @NAME@ is a @AGE@ @SEX@ who presents with (chief complaint). The patient reports that (duration) he/she developed a (onset) of (timing) (location) (chief complaint) (radiation). He/she describes it as (character/nature) and rates it as a (intensity). He/she affirms (associated symptoms). He/she denies (associated symptoms). The patient states that (context). Symptoms are (modifying factors). The patient has (treatment before arrival).Let’s do an exercise in which we complete this templated history for a fictional patient with a chief complaint of abdominal pain. The Minimal Data Set (see addendum) should be obtained and the provider should meet with MDS coordinator to review results of new admissions and obtain orders to evaluate patient for psychiatric or behavioral problems and confirm that MDS coordinator evaluation is consistent with provider’s evaluation in terms of psychiatric diagnoses or cognitive impairment.EXAMPLE 1: Example of Psychiatric History form from Senior PsychCare (see addendum) @NAME@ is a @AGE@ @SEX@ who presents with (abdominal pain). The patient reports that (2 days ago) he/she developed a (gradual onset) of (constant) (right upper quadrant)(abdominal pain)(radiating into the back). He/she describes it as (throbbing) and rate is as a (5/10). He/she affirms (nausea, vomiting, and diarrhea). He/she denies (hematochezia, shortness of breath, or chest pain). The patient states that (with prior episodes of cholelithiasis they have had similar symptoms). Symptoms are (worsened by eating). The patient has (taken over the counter antacids with little relief).In Example 1, notice that the history is well organized. Although it is quite simplistic compared to what would likely be constructed in a real scribing situation, it is a great example that demonstrates how a history can be created with logical order and good flow by using the billable elements as a template. A good self-check to assess organization is to read the history aloud (even if just whispered), as if you were telling somebody about this patient. If the story doesn’t make sense in the manner that it’s told, then the organization probably needs to be altered.Let’s do another exercise in which we complete this templated history for a fictional patient with a chief complaint of shortness of breath.EXAMPLE 2: @NAME@ is a @AGE@ @SEX@ who presents with (shortness of breath). The patient reports that (last week) he/she developed a (sudden onset) of (progressively worsening) (shortness of breath)(location)(radiation). He/she describes it as (character/nature) and rate is as a (intensity). He/she affirms (palpitations and light headedness). He/she denies (chest pain or leg swelling). The patient states that (the shortness of breath began after running a marathon). Symptoms are (exertionally worsened). The patient has (tried relaxing in a spa with little benefit).In Example 2, note that several billable elements were not used (location, radiation, character/nature, and intensity). Remember, these billable elements should only be used for pain or other sensory changes. Example 2 demonstrates that not all billable elements can be used in every history, but in most cases they can certainly be used as a generic starting place. Realistically, in an actual scribing situation, a template like the one that was used in the first two examples will not be used. After the chief complaint is obtained from elsewhere in the chart, the history should be synthesized as the provider is interacting with the patient. There will be other elements of the history that will complicate the history-writing process. For the sake of simplicity, let’s refer to these collectively as “additional history”.Additional history, including past medical history, family history, social history, surgical history, medications, and allergies, may all be inquired about during the encounter and should be included in the history. Remember, if the provider asks a question, the answer is likely important! Additional history can be recorded in two ways. It can either be included throughout the history, as long as the placement makes sense, or can be written preceding or following the main body of the history.Let’s do another exercise in which we create a history for a patient with a chief complaint of chest pain. This time the templated history will not be used, and the content of the history will be a bit more complex. While reading this, try to identify the billable elements in the main body of the history. Also try to identify the elements of additional history, which are located at the end of the history in this case.CHAPTER 8: ADDITIONAL ROLES OF A TECHNICIANNot only can the psychometric technician help the provider complete various parts of the chart, but they also perform duties within the medical record that are relevant to the patient’s stay. Because a scribe is a “non-clinical” person, the provider must specifically ask the scribe to do these things and then review and sign the scribe’s work before it is acted upon. These duties may include placing orders for testing and imaging, completing prescriptions for the patient to take home, and completing the patient’s disposition paperwork when the provider has determined the patient’s final status.PRESCRIPTIONS (Senior PsychCare does NOT approve our staff prescribing narcotics)Prescriptions are order for medications, testing such as lab or imaging, or requests for other healthcare items that are sent home with a patient and are meant for the patient to use or complete at a later time. Prescriptions can be either electronic or written. Prescriptions that are created for different types of orders will vary and the types of prescriptions will differ between specialties as well. The pharmacist may receive documentation of certain psychotropic medications based on CMS guidelines but professionals do not need to comply if they think it is contraindicated and must be indicated in chart.Writing for prescriptions: There are certain safeguards in place in the electronic medical record that allows the scribe to create prescriptions. These include “hard-stops” after a scribe places orders or creates prescriptions. The hard-stops prevent the order or prescription from being acted upon unless the provider has reviewed, approved, and signed the scribe’s work. In addition to the hard-stops, the electronic medical record should also send notification to the provider (such as medication contraindications including allergies or drug-drug interactions), even if they were sent to the scribe first. Please note: the ability to enter orders is determined by the legal/compliance department where you are working. Basic elements of a prescription: Although the types of prescriptions may vary, there is a generalized formatting that you may expect to see. Below is a list of generic elements you may see in a medication prescription, along with some examples. Other prescriptions may require different elements: however, we will only discuss medication prescriptions here, as these are the most common type that a scribe may encounter.Generic versus trade name: As a general rule, both the generic and trade name will be listed.Dose: Amount of drug to be given.Examples: weight (e.g. milligrams (mg)), volume (e.g. milliliters (ML) or drops), number (e.g. capsules, tablets, patches, puffs, etc.)Physical form of the drug:Examples: tablet, capsule, cream, ointment, aerosol, patch, etc.Modifiers: extended release (ER), chewable, disintegrating, etc.Route: The manner in which the drug should be administered.Examples: orally (PO), per rectum (PR), by inhalation or intranasal, topical, intravenous (IV), intramuscular (IM), subcutaneous (SQ), via PEG tube or J tube, sublingual (SL).Frequency: Frequency that a drug should be administered.Examples: qd (once daily), bid (twice daily, or every 12 hours), tid (thrice daily, or every 8 hours), qid (four times daily, or every 6 hours), or qhs (at bedtime), prn (as needed).Duration: Period of a time over which the drug should be taken, written in number of days. There is also an option to modify start and end dates that is often used for controlled substances.Patient Sig: Any other specifications describing “how” a patient should take a drug or “why” they should be taking it can be free texted here.Dispense: The definite quantity of the medication that should be given to the patient by the pharmacy (e.g. 15 tablets). Typically used for controlled substances or for as need (prn) medications. DAW (dispense as written): The pharmacist can fill any trade name drug with the generic equivalent unless the prescription explicitly forbids this, designated with “DAW” (dispense as written). DAW is typically used in circumstances in which the patient is unable to tolerate anything but the trade name drug, for a variety of reasons.Regulations: Senior PsychCare does not use narcotics for medical legal reasons but scheduled psychiatric drugs. If pain management is required using narcotics please have the facility require it. A pain specialist should be required to follow the patient. The Drug Enforcement Administration (DEA) is a federal agency that is under the auspices of the Department of Justice. It is tasked with enforcing the Controlled Substances Act along with the Federal Bureau of Investigation (FBI) and Immigration and Customs Enforcement (ICE). Although the DEA has a large role in controlling the sale and distribution of illegal drugs, for our purposes we will focus on its role in controlling the distribution of legal narcotics and other controlled substances. The DEA verifies authorization to write for controlled substances or any drug with abuse potential. This includes, but is not limited to, narcotics, sedatives, or amphetamine-like substances. The DEA also maintains a registration system for persons and organizations who are permitted to prescribe or otherwise use substances listed as controlled.When an entry (in our case, provider), applies for a number, they are requesting permission to write prescriptions for certain classes of controlled substances. Different practitioners may have different levels of prescriptive authority and may only write for drugs that fall into those categories for which they have been approved. A prescription can be called-in by a designated employee of the physician as long as it is not a medication with high abuse potential.Senior PsychCare does not approve providers prescribing narcotics or prescription of other professionals.The DEA number consists of 2 letters followed by 7 numeric digits. There is a formula for these numbers that is not important to know, but it makes it possible for someone (say a pharmacist) to recognize a made-up number in many cases. There are other identifiers like the National Provider Identifier (NPI), which is given to every provider by the Centers for Medicare and Medicaid Services (CMS) that pharmacies and others can use to track the prescriber.When writing prescriptions, it is important to know that they may fall into different DEA categories called medication schedules that are based on abuse potential and legitimate use for medical purposes. Schedule I drugs have a high abuse potential and have no accepted medical indications. Heroin or LSD are never legally prescribed. Schedule II drugs have a high abuse potential but can be prescribed for certain medical conditions (e.g. oxycodone). Schedule III drugs have a lower abuse potential and do have accepted medical uses (e.g. butalbital). Schedule IV drugs have a low abuse potential and accepted medical uses (e.g. tramadol). Schedule V drugs have a very low abuse potential and accepted medical uses (e.g. promethazine with codeine cough syrup). Non-controlled medications do not require a DEA number on the prescription.Every prescription for a scheduled substance must have the following: 1) patient’s full name and address 2) provider’s full name and address 3)provider’s DEA number; 4)basic elements of a prescription such as drug name, dosage, form, number prescribed, number of refills, sig, etc: 5) provider’s signature.ORDERSOrders can be created for a variety of things, including medications, lab work, other testing, imaging, or communications that are meant for other healthcare workers. Orders will vary depending on specialty, or even by provider with the same specialty. They can either be performed on-site, as in the ED or some outpatient facilities, or can be prescribed for future use.Justification for orders: In any setting, justification for orders must be provided for billing and insurance reasons. The electronic medical record will typically prompt for this, when needed. However, they type of justification required may vary depending on the medical facility (emergency department versus inpatient versus outpatient).ED/patient: A written reason for an order must sometimes by provided. This is typically required for any type of imaging study. In EPIC, this appears as a blank text box requiring a written reason. There may be drop-down choices in some electronic medical records.Outpatient: ICD-10 codes, which are an algorithmic set of numbers and letters used to designate each clinical impression or diagnosis in the electronic medical record, should be associated with (in other words, attached to) each order. In EPIC, this usually entails a pop-up box with a grid listing of orders and ICD-10 codes. There will generally be a prompt to check the boxes associated with an ICD-10 code and an order. This may look somewhat different in other EMRs.Writing for orders: There are certain safeguards in place within electronic medical record that allow the scribe to enter orders. These include “hard-stops” after a scribe places orders or creates prescriptions. The hard-stops prevent the order or prescription from being acted upon unless the provider has reviewed, approved, and signed the scribe’s work. In addition to the hard-stops, the electronic medical record should also send notifications to the provider (such as medication contraindications including allergies or drug-drug interactions) even if they were sent to the scribe first.Types of orders: The following is a list of some of the most common orders that may be seen in the emergency department, organized by order type, in addition to a concise description of what each order entails. Based on your duties as a scribe, it would be the most helpful to understand the spellings and abbreviations of each order. However, a deeper understanding of what each order entails, and thus the circumstances under which it may be ordered, will allow you to anticipate what a provider may ask you to order for a variety of complaints and can help to improve your speed and accuracy. Admission Orders: in order for Senior PsychCare staff to see a patient we must have a written or verbal order form the primary care physician.Medications: See Chapter 5, “Medications”Labs: Include any number of tests run from samples of bodily fluids, (including blood, urine, stool, fluids apart from wounds, the mouth, skin lesions and others not listed here. Specimens may be sent to measure certain chemical components (such as electrolytes), to culture (see what organisms grow), to obtain cell counts, or to obtain pathology analysis. The following are some categories of lab tests with some examples in each category. Discharge note is required and you are to use SPC standard discharge note (see addendum). Discharge is sending the patient back home to a more permanent like an extended care facility (ECF)., nursing home, or skilled nursing facility (SNF). This occurs when the medical provider has “cleared” the patient meaning the patient is deemed safe from any acute medical issues.AMA (against medical advice): Although it is ideal for the patient to remain in the emergency department until a decision is made regarding the most appropriate disposition, sometimes a patient may decide to leave before their evaluation is complete. This is called leaving against medical advice, or eloping if they don’t stay for the explanation detailing why the provider believes it is in the patients best interest to stay, and happens for a variety of reasons. If the patient leaves against medical advice, the provider will give the patient discharge instructions with the safest plan of care (given the circumstances) and also discuss possible consequences of leaving before their evaluation is complete. If they have eloped, these instructions will not be possible. If a patient is a danger to their self or others, the police should be notified and documentation occur.A patient may also leave without being seen (LWBS). This is a different situation in which a patient may check into an emergency room at triage (the front desk), but leave before being brought to a room or otherwise seen by the physician or other provider. In this case, the provider is not given the opportunity to evaluate the pleting a disposition: A scribe may be involved in helping their provider complete dispositions in the electronic medical record. A scribe will not make any decisions regarding disposition, but may enter what is told to them by their provider. Below are various elements that may need to be completed prior to a disposition change. Various dispositions will require different elements, and this is noted as well.Disposition: Status change of the patient, required for all dispositions. In the electronic medical record, this appears as an option to select admit, transfer, discharge, or AMA. Making this selection will officially change the patient’s status.Condition: The patient’s medical condition at the time of disposition. This is required for all dispositions.Examples: good, fair, stable, serious, poor, or critical.Follow-up instructions: Recommendations for outpatient follow-up given to discharged patients to use after leaving the hospital. Follow-up could include the following: 1. Follow up with their primary care physician or consultant or SPC staff within “x” amount of days; 2. Return to the primary care physician if symptoms worsen; or 3. Follow-up with additional specialists (if applicable) for further evaluation. You will generally be asked to include the first two, as this is the standard after emergency department visit care.Work/school excuse: A written excuse for work or school or elsewhere stating that the patient was seen in the facility on that date, and giving any specific instructions for limitations. This can be given to patients who are being discharged, but is not required. These should be signed by the provider prior to being given to the patient.Discharge instructions: Specific instructions, from a template or free texted, given to a patient prior to discharge. Typically describes the diagnosis and how the patient can care for themselves at home and whether the patient would be accepted again if he returns.Orders: Any order the provider requires for this disposition. This can be used for any disposition, but is not required. For admitted patients, this could include medications or treatment that the patient will need prior to entering the hospital. You may also be asked to enter an “ED contact order”. This is a request for the receptionist to page te hospitalist or another specialist so the emergency medicine physician can discuss the patient’s case and confirm he status change. For discharged patients or patients who leave against medical advice, orders could include medications or treatment that the patient needs prior to discharge, or prescription for them to take with them.Clinical impression: Typically ascertained after a rapid work-up in the emergency department. It is an assessment of the patient’s condition based upon their symptoms and results, but is usually not a diagnosis. Clinical impressions are required for all dispositions.A diagnosis is more definitive term used to describe a disease or condition (see DSM-V). Typically, sign and symptoms codes are used when a definitive diagnosis has not yet been made or the patient’s presentation is not explained by a relevant diagnosis. When a diagnosis is found that explains the signs and symptoms, it is not necessary to report the signs and symptoms any longer.A problem list contains all current medical problems that a patient is known to have. This may include final diagnosis, symptoms or signs, or clinical impressions. Every patient is different and may have multiple “problems” in their problem list.Problem lists are used as a reminder to the provider to document on each of hte items in the list that pertain to the situation. For example, a patient is admitted with several problems. The hospitalist will likely document on each of these problems individually when writing their progress note for the day. For example, “the hypertension is well controlled, has been placed the pneumonia is still causing some dyspnea, but the patient has bene placed on antibiotics for it.A specialist might document only on the problems that fall under their area of expertise. For example, the cardiologist on the case will comment on the EDG and the patient’s heart enzyme test (troponin), as well as discuss and order testing for that specific problem. Another example: A surgeon might follow up the surgical incision that they made and any postoperative complications, such as fever.The problem list is carried from provider to provider and should be updated appropriately. It is the responsibility of the provider to manage the problem list. This often includes “cleaning up the list”, which entails removing old or irrelevant, erroneous problems that have been entered at some time in the past. Wherever there is a diagnosis or new problem, there should be documentation on that problem. It is permitted and desirable for the scribe to assist the provider with remembering to document on all active problems that are relevant to that provider. The provider decides what that documentation will entail.Diagnoses, clinical impressions, and problems are recorded using ICD-10 (tenth revision of the International Statistical Classification of Diseases and Related health Problems) and the DSM-V diagnosis. Physical issues affect mental health and we have a responsibility to refer to PCP for referral to specialty physician. There are tens of thousands of choices and there must be a code associated with each encounter in order to submit a bill.Codes consist of a series of numbers and letters. Number places are reserved for certain descriptors, increasing in specificity from larger to smaller numbers places. Generally, numbers places follow these rules:First 3 characters: category of diseaseFourth character: etiology of diseaseFifth character: body part effectedSixth character: severitySeventh character: placeholder (for increased specificity)Modifiers: may be added to explain unusual circumstancesFor example: Osteoarthritis is represented by the ICD-10 code M19. The three etiologis of osteoarthritis are represented by three different numbers in the tenths place (primary is M19.0, post-traumatic is M19.1, secondary is M19.2, and unspecified is M19.9). The body part affected is represented by five different numbers in the hundredths place (shoulder is M19x1, elbow is M19x2, and unspecified is M19.xx9). This is a perfect example to demonstrate that, although each numbers place generally follows the rules given above, this is not always the case (per the rules above, the thousandths place is normally reserved for severity).For the sake of billing, it is always best to use the most specific ICD-10 code possible. For example, instead of using nonspecific “abdominal pain, “ try using specifics such as quadrant or chronicity pattern. This will ensure that the provider will get paid for their work. CHAPTER 9: OPTIONAL PRACTICEThis chapter was created in order to offer additional opportunities to practice some of the skills taught throughout this text. Because the practice is limited logistically (without an electronic medical record you cannot practice for the history, billable, elements, review of system, and physical exam. The general skill set required for this practice is ubiquitous, and thus the practice can still be useful in developing basic scribing skills.Because many healthcare facilities have transitioned to the electronic health record, or are in the process of doing so, it would be best to use a blank document on a computer to practice. Using a computer will more closely simulate a real life scribing situation, and will provide an opportunity to practice typing.A blank sample chart is provided on the next page to serve as a reminder of the formatting of the chart that was explored in earlier chapters. Remember, the first sentence should provide the patient’ age, sex, and chief complaint. The second sentence should then say “the patient (or other historian) states/reports…”Please use the following step-by-step explanation describing “how” to complete the practice:A dialogue from a fictional encounter between a patient and a provider will be given. Synthesize a history from this dialogue. Each dialogue will be based on one of the chief complaints discussed in detail in Chapter 8, “Pertinent Questions”. Pay special attention to the questions asked and how they relate to the skills that were learned in previous chapters.With the information in the written history, place the billable elements in the proper locations within the billable elements plete the review of systems by placing the symptoms from the history into the proper locations within the review of systems template.After the dialogue, a short list of physical exam finding will be given. Practice placing these findings into the correct system within the physical exam pare the chart you have created with the one given in the “answer key.” “Answer key” is in quotation because every history, by nature, will be unique. There are, however, key elements that should be included in the history you have created. These should be easy to identify. Additionally, symptoms and signs in the review of systems and physical exam findings can sometimes be placed into multiple systems. If you have placed them in systems other than what is noted in the “answer key”, you are not necessarily wrong for doing so. Refer to Chapter 12, “Medical Terminology Index,” for additional information.Read through the “key points” section concluding each practice example. This section will explain the pertinent questions that should have been included in the history, in addition to key learning points about each case.SAMPLE HISTORY:HISTORY OF THE PRESENT ILLNESS (HPI)@NAME@ is a @AGE@ @SEX@ who presents with ***.DESCRIPTORS (BILLABLE ELEMENTS)Duration:***Onset:***/Timing***Location: ***/Radiation: ***Character/Quality: ***Intensity: ***/Severity:***Associated Symptoms: ***Context: ***Modifying factors: ***/Tx before arrival: ***REVIEW OF SYSTEMSConstitutional: ***Eye: ***HENT: ***Resp: ***Cardio: ***GI: ***GU: ***Musculoskeletal Extremities: ***Neuro: ***Skin: ***PHYSICAL EXAM and MENTAL STATUS EXAM (see addendum)Constitutional: ***Eye: ***HENT: ***Lymphatic: ***Endocrine: ***Neck: ***Cardiovascular: ***Thorax &Lungs: ***Abdomen: ***GU: ***Skin: ***Musculoskeletal/Extremities: ***Back: ***Neurologic: ***Psychiatric: ***DIALOGUE 1: The patient is a 53 year old male who presents with chest pain.Provider: I’ve reviewed your SDG and I see some concerning changes. Tell me about your chest pain.Patient: About an hour ago, I was shoveling snow and all of a sudden began having sharp chest pain (points to sternum) that moved to my left jaw and shoulder. I couldn’t catch my breath and soaked my clothes with sweat. I had to go change my shirt before I called 911.Provider: Were you nauseated or vomiting? Any recent coughs or fevers.Patient: I have cough normally because I smoke. But it hasn’t changed and I don’t cough anything up.Provider: You said your pain was sharp. Does it worsen when you breathe?Patient: No, but I did notice that it got worse when I continued to shovel snow.Provider: Do you have diabetes, high blood pressure, or high cholesterol?Patient: My family doctor says I have all of those but I’ve gotta be honest with you doc. I don’t take my medications, even though I tell my family doc that I do.Provider: Have you ever had a heart attack or been told that you have heart disease?Patient: No, I’m a healthy guy. Never seen a cardiologist in my life.Provider: Does anyone in your family have heart problems?Patient: My dad and his dad both had major heart attacks. And my uncle had diabetes, I think.Provider: I was told that the paramedics gave you nitroglycerin when they picked you up. Did that relieve your pain at all?Patient: It did! My pain is a 2/10 now, and before it was a 10/10.Provider: Do you take any blood thinners?Patient: I don’t like taking any medications. So I haven’t taken any of that stuff.Provider: Do you have any visual changes, a sore throat, abdominal pain, burning with urination, leg pain or swelling ,headaches, rashes, or any other symptoms?Patient: None of that. Like I said – I’m a pretty healthy guy.PHYSICAL EXAM FINDINGS EXAMPLE 1: Well developed and obese male. Mucous membranes are dry but otherwise normocephalic and atraumatic. There is a JVD. Heart is tachycardic and an occasionally irregular rhythm. There is a 3/6 systolic ejection murmur but no rubs or gallops. Breath sounds are normal but diminished throughout. No chest wall tenderness. Abdomen is soft and non-tender. He is diaphoretic. 1+ pitting edema bilaterally. No calf tenderness. REVIEW OF SYSTEMSConstitutional: Positive fever and chills.Eye: No visual changes.HENT: Positive sore throat, rhinorrhea, congestion.Resp: Positive nonproductive cough, dyspnea, pleuritic chest pain.Cardio: No leg pain or swelling.GI; No nausea, vomiting, or diarrhea.GU: No dysuria or hematuria.Musculoskeletal/Extremities: Positive post tussive chest pain.Neuro: no headaches.Skin: No rash.PHYSICAL EXAMConstitutional: Well developed and well nourished femaleHENT: Moist mucous membranes. Nose is congested with scant clear rhinorrhea. Posterior oropharynx somewhat erythematous, but no tonsillar swelling or exudates. TMs clear bilaterally.Lymphatic: No anterior cervical lymphadenopathy.Cardiovascular: Borderline tachycardia. Regular rhythm. No murmurs, gallops, or runbs.Thorax & Lungs: Few end expiratory wheezes, but otherwise normal breath sounds. No chest wall tenderness.Abdomen: Soft and non tender.Skin: Normal capillary refill to the lower extremities.Musculoskeletal/Extremities: No calf tenderness. Negative Homan’s sign. Strong DP/PT pulses.Neuro; No focal deficits. PSYCHIATRICREVIEW OF SYSTEMSAnger outbursts – episodes of angerAnxiety – feeling uneasyAuditory hallucinations – hearing things that are not thereDepression – having a depressed mood or loss of interest in abnormal activities for a prolonged period of timeHomicidal ideation – thoughts of homicideManic episodes – abnormally elevated arousal, affect, and energyNon-restorative sleep – waking up feeling unrefreshedParanoia – thought os suspicion or mistrust that can be unrealistic or unwarrantedSleep disturbances – any disruption in sleepSuicidal ideation – concern, thoughts about , or an unusual preoccupation with suicideVisual hallucinations – seeing things that are not thereMEDICATION INDEXPsychiatric:Antidepressants:amitriptyline/Elavilpregabalin/Lyricaduloxxetine/Cymbaltamilnacipran/Savellavenlafaxine/Effexorparoxetine/Paxilfluoxetine/Prozacbupropion/Wellbutrincitalopram/Celexasertraline/Zoloftescitalopram/LexaproBenzodiazepiinesalprazolam/Xanaxclonazepam/Klonopinlorazepam/Ativandiazepam/Valiumtemazepam/RestorilCNS (central nervous system) stimulatorsmethylphenidate/Concerta or Ritalindextroamphetamine/Adderallamphetaime/VyvanseAntipsychoticshaloperiod/Haldolziprasidone/Geodonaripiprazole/Abilifyrisperidone/Risperadolquetiapine/SeroquelSedativeszolpidem/AmbienMiscellaneousvalproate/DepakoteCHAPTER 10: SUCCESSFUL TECHNICIAN: INSIGHT FROM EXPERIENCEThe following is a compilation of “non-clinical pearls” – small tidbits of advice given by experiences scribes who have worked for, or are, currently employed by, ABC Scribes. These scribes were once in your shoes, new to the profession of medical scribing and are very familiar with the challenges anew scribe may face. These non-clinical pearls will be an immensely useful resource in your own journey as you strive to improve your sill set.If you could go back in time and give yourself advice on your first day of scribing, what would you say?Being a technician is a learning journey. It is important to always do your best but do not stress yourself out, taking away the enjoyment of the opportunity that is being a scribe. Take any criticism given as constructive critiques, used to better yourself as a medical scribe. KL emergency department.Relax. You learn most of the technician skills as you work. You will pick it up quickly but be patient with yourself. – PB emergency departmentA positive attitude goes a long way! There will be times when you fell intimidated by the workload in front of you, but just keep moving forward! Rely on your training and your instincts, and don’t be afraid to ask questions. – ED orthopedicsDon’t be too nervous or afraid. Even though you are now part of someone’s experience in healthcare, you don’t need to be overwhelmed by the pressure to not make a mistake. Your trainer will be there for you to help you learn how to catch every important piece of information. Your first few shifts not only teach you how to scribe, but how to work as a part of the healthcare team and develop important lines of communication. If you focus on being the best part of the team that you possibly can, then you will succeed. – KD emergency department, family medicineI would carry all of the essential tools that I need on the job (badge, pen, post-its, prior background research on the doctors) and would arrive 15 minutes early so that I cold print the tracing sheet and become acquainted with the ED setting. J- RE emergency department, family medicineComprehensive, attentive listening, and observation has helped me to attain all of the necessary information for the record, and to guide questioning for my doctor. Being very observant and listening to all correspondences will help you feel like a well-informed scribe, who is ready to ask intelligent and meaningful questions. – WR orthopedicsWhat things did you do to improve speed/efficiency in completing a chart?Fall into a rhythm. The more you chart, the more you become comfortable with it. – PB emergency department, inpatientGetting more comfortable with the vocabulary and recognizing the flow of your physician is helpful in becoming an efficient scribe. If you know the order in which a physician executes their patient encounter, you will be more prepared for when they will communicate with you. Also, work a ton and you’ll have no problem with becoming speedy! – KD emergency departmentUsing every chance to shave the “fluff” out of your HPI. If you know medical terminology and can identify important information, you will be able to form concise, packed, informative sentences that take less time to type. Also use any opportunity to pre-chart. Even if you have to mae changes in the room, pre-charting can provide the first few sentences, givng you more time in the room to edit, revise, and possibly even finish your note. – SK emergency departmentStudy the medical terminology! While I am in the patient’s room I sometimes use abbreviation in my note, then, once I have more time outside the room, I go back and edit the notes and add more detail. –WL emergency departmentGenerally, my efficiency improved as I learned the nuances of my physician, as well as the pacing and particulars of the facility’s flow of operations. When I am caught up on my current charting duties, I review and note the incoming patient’s histories. This not only prepares my mind for the encounter, but also serves my doctor well. Pre-charting past studies and treatments can improve the thoroughness of aa record and help with efficiency. – WR orthopedicsWhat was the most useful tool you used to learn and understand all of the medical terminology?Google and the physicians I work with. – PB emergency department, inpatientStudy. Google. If you find yourself looking up the same term over and over, write it in your notebook and study it on your own time. A polished vocabulary will not only make your notes sound incredibly more professional, but it will save you time too. – SK emergency departmentI keep a little notebook with new words that I learn on shift. I am still learning words a year into scribing and it is helpful to have a place to write everything down to reference for future charts. I also try to talk to doctors during their free time to learn more. – WL emergency departmentI made flashcards and continued to look over those even after starting my job. Along with that, listen to your physician. They will use medical terminology and describe what they mean to the patients. – VF family medicineHow did you prepare for your shifts as a new scribe?I would arrive to my shifts thirty minutes early to print and make notes on the tracking sheet describing who was working in the department that day. This helps your physician out too, sometimes, I also bring food because the shift are long. – KL emergency departmentI prepared for shifts by arriving early and always keeping track of when patients arrive so that I am not surprised or rushed when the doctor assigns themselves to a new patient. As soon as the doctor does this, I am prepared to write the essential information on the tracing sheet and open a note so that I am ready to go see that patient. – RE emergency department, family medicineI started keeping a small, alphabetized note pad in my pocket. I wrote down he information specific for my job. I used this as a reference guide on the job that I could refer to quickly, improving my efficiency and minimizing disruption to my physician’s workflow. – ER orthopedicCMS guidelines to provide care and receive payment for services.11 Treatment PlanningINTRODUCTIONGuide to Creating Mental Health Treatment Plans (Refer to SOAP notes)Psychiatrists, psychologists, mental health counselors, social workers and other behavioral health professionals use treatment planning as a tool to effectively treat patients. Without a clear plan in place, it can be hard to track progress, stay organized and keep a record of individual patient care.Every patient needs individually tailored treatment. When a mental health professional creates a comprehensive treatment plan specifically designed to meet their patient’s needs, they give their patient directions towards growth and healing. Although not all mental health professionals are required to produce treatment plans, it’s a beneficial practice to both the counselor and the patient. In this guide, we’ll how you why mental health treatment plans are essential and how to create psychiatric treatment plans that will make a difference in your and your patient’s lives.WHAT IS A TREATMENT PLAN?A treatment plan is a detailed plan tailored to the individual patient and is a powerful tool for engaging the patient in their treatment. Treatment plans usually follow a simple format and typically include the following information:The patient’s personal information, psychological history and demographicsA diagnosis of the current mental health problemHigh priority treatment goalsMeasurable objectivesA timeline for treatment progressSpace for tracking progressSOAP notes are important for the nursing home staff and other professionals to coordinate their treatment plan whose procedure and interventions may differ from professionals. See SPC SOAP notes for nursing home staff.WHAT IS THE PURPOSE OF A TREATMENT PLANThe purpose of a treatment plan is to guide a patient towards reaching goals. A treatment plan also helps counselors monitor progress and make treatment adjustments when necessary. You might think of a treatment plan as a map that points the way towards a healthier condition. Without a treatment plan, a patient has no clear direction on how to improve behaviors, negative thinking patterns and other problems impacting their lives.Treatment plans provide structure patients need to change. Model and technique factors account for 15% of a change in therapy. Research shows that focus and structure are critical parts of positive therapy outcomes. Goal setting as part of a treatment plan is beneficial in itself. Setting goals helps patients:Achieve moreStay motivatedFeel satisfiedBoost self confidenceConcentrate betterAvoid confusionAvoid feeling overwhelmedSet prioritiesTreatment plans also help therapists and behavioral health staff with documentation. Treatment plans contain essential information about a patient’s progress in a clear and organized format with details such as dates, names and measurable goals. With this information readily available, writing a progress note becomes an easier part of the job.THE GOALS AND OBJECTIVES OF MENTAL HEALTH TREATMENT PLANSTreatment planning is a team effort between the patient and the counselor. Both parties work together to create a shared vision and set attainable goals and objectives. A goal is a general statement of what the patient wishes to accomplish. Examples of goals include:The patient will learn to cope with negative feelings without using substancesThe patient will learn how to build positive communication skillsThe patient will learn how to express anger towards their spouse in a healthy wayAn objective, on the other hand, is a specific sill a patient must learn to reach a goal. Objectives are measurable and give the patient clear directions on how to act. Examples of objectives include:An alcoholic with the goal to say sober might have the objective to go to meetings.A depressed patient might have the objective to take antidepressant medication with the goal to relieve depression symptoms.A patient in a recovery program might have the objective to keep a daily assertiveness log with the goal to learn healthy communication skills.Simply said, an objective is a specific way to reach a goal.Tips for Identifying Goals & Objectives for PatientsEveryone is different, and so is every treatment plan. A counselor must use their skills to help a client establish the best goals and objectives for their unique condition. Counselors can ask themselves these questions to help uncover the best goals for their patients:What is the patient doing that is unhealthy?What does the patient need to do differently to change unhealthy behaviors?How can I help the patient change the behaviors?After you’ve realized the goals, you can determine the objectives by asking yourself:What does the patient need to do to accomplish the goals?What can I do to help them with objectives?Patients play an important role in developing their treatment plan. Although you will use your professional knowledge to facilitate treatment planning, patients must participate in the following ways:The patient must understand they have a problem.They must understand precisely what their problem is and how it affects them.They must be willing to learn skills to solve the problem in a healthy way.HOW TO WRITE A MENTAL HEALTH TREATMENT PLANGoal setting is only part of the treatment plan process. You’ll need to gather information and conduct a mental health assessment before creating a treatment plan. You’ll also need to identify and discuss possible goals with your patient. After an assessment and discussion, you’ll be ready to create a treatment plan which both you and your client will need to sign.Treatment planning is an ongoing process. You’ll review and revise the treatment plan as needed and nothing is written in stone. A mental health treatment plan template will help you stay organized, but the information it holds is unique to the client and open to changes.Treatment Plan TemplateA treatment plan is simple but specific. Although treatment plans vary, a treatment plan template or form generally contains the following fields:Patient information: At the top of the treatment plan, the counselor will fill information such as the patient’s name, social security number, insurance details and the date of the plan.Diagnostic summary; Next, the counselor will fill out a summary of the patient’s diagnosis and the duration of the diagnosis.Problems and goals: The third section of the treatment plan will include issues, goals and a few measurable objectives. Each issue area will also include a time frame for reaching goals and completing objectives. Counselor should strive to have at least three goals.Signatures: The final section of the treatment plan is where the counselor and the client sign their names. This signifies that the patient participated in developing the treatment plan and agrees with the content.Mental Health Treatment Plan ChecklistTo ensure you don’t miss any crucial details, use this checklist as a helpful reminder:Issues: Do the issues reflect the six problem domains which are medical status, employment, substance abuse, legal status, family or social status and psychiatric status? Are issues written in behavioral terms and a non judgmental manner? Are they prioritized?Goals: Do the goals address the listed issues? Are they attainable during treatment? Does the patient understand the goals as written? Does the client seem ready to change and accomplish the goals?Objectives: Do the objectives address the goals? Are the objectives measurable and specific? Can the client take the time or steps necessary to complete objectives? Is there a time frame for the objectives? Are they realistic for the patient’s current situation? Does the client understand what is expected of them?General: Is the treatment plan customized to suit the patient based on their unique skills, goals, lifestyle, educational background, culture and socioeconomic status? Are their strengths incorporated in the treatment plan? Has the patient participated in developing the plan? Is the plan dated and signed by all parties who were involved in creating the treatment plan?MENTAL HEALTH TREATMENT PLAN TIPSThere are no set rules for developing a treatment plan for your patient because every plan is unique. However, we’ll look at a few tips to help you through the goal setting and planning process.Measure SuccessTo evaluate the effectiveness of the treatment plan, you need to keep score of how the patient is doing. Ask the patient to count and keep track of their thoughts, feelings, and behaviors in a log so you can monitor their progress.Set SMART GoalsWork with your patient to set goals and objectives they can actually reach. Use the rules of SMART for guidance. SMART stands for the following:Specific: Objectives need to be clear and specific, not general or vague. It’s easier for a patient to complete objectives when they know exactly what they need to do.Measurable: Objectives need specific times, amounts, or dates for completion so you and your patients can measure their progress.Attainable: Encourage patients to set goals and objectives they can meet. If their objectives are unrealistic, it may decrease their self confidence or discourage them. However, goals and objectives should not be too easy either. Goals should be challenging but also realistic.Relevant: Goals and objectives should be relevant to the issues listed in the treatment plan. When patients complete objectives and reach their goals, they should be closer to the place they want to be in life and as a person.Time bound: Goals and objectives must have a deadline. Goals might be considered short term or long term, while objectives need specific dates to meet. A deadline creates a sense of urgency which helps motivate clients.Set Goals That MotivatePatient are more likely to complete objectives and work towards reaching a goal if the goal is personally important to them. If a goal does not add value or meaning to their life, they will not have the motivation to work through objectives.Ask clients to discuss goals that have the most meaning to them. Make sure the goals are in order of importance so patients can focus their priorities.HOW A MENTAL HEALTH TREATMENT PLAN COMPLEMENTS OTHER THERAPY NOTESTreatment plans not only help the patient, but they also serve the entire behavioral health team. A treatment plan is a toold that promotes good communication between staff members and helps provide documentation necessary for billing. As part of a patient’s medical health records, treatment plans also help facilities comply with federal and state laws. Let’s look at a few ways mental health treatment plans assist with record keeping.Psychiatric EvaluationA psychiatric evaluation involves using tools to measure and observe a client’s behavior. By evaluating a client, a psychologists can determine a diagnosis and develop a treatment plan. A treatment plan helps organize this information in one neat document. The treatment plan also allows for quick reference of the initial evaluation when staff members or counselors need to revisit the evaluation in the future.Progress NotesTreatment plans and progress notes go hand in hand because progress notes need to incorporate one or more treatment objectives. Progress notes are essential for communicating patient care and getting reimbursed for services. A treatment plan helps staff meet progress note requirements and keep track of how a patient is doing. Progress notes typically include:The treatment planAny changes in the client’s conditionDescriptions of a client’s response to treatmentThe outcome of treatmentDischarge SummaryWhen patients are ready to leave a treatment program, a discharge summary is needed to document how the patient completed the treatment and what their plan for continuing care is. A treatment plan can guide the writing process when it’s time to produce an accurate, detailed discharge summary.Evaluation of Nursing Facility Resident Safety During Implementation of the INTERACT Quality Improvement Program (full article in Resource Manual)Ruth M Tappen EdD, RN, FAAN, David Newman PhD, Peter Huckfeldt PhD, Zhioyou Yang BS, Gabriella Engstrom, PhD, RN, David G Wolf PhD, ACHCA, CNHA, CALA, CAS, Jill Shutes GNP, Carolina Rojido MD, Joseph G. Ouslander MD.ABSTRACTBackground: Medicare incentivizes the reduction of hospitilizaitons of nursing facility (NF) resdients. The effects of these incentives on resident safety have not been examined.Objective: Examine safety indicators in NFs participating ina randomized, controlled trial of the INTERACT Quality Improvement Program.Design: Secondary analysis of a randomized trial in which intervention NFs exhibited a statistically nonsignificant reduction in hospitalizations.Setting: NFs with adequate on site medical, radiography, laboratory, and pharmacy services, and capability for online training and data input were eligible.Participants: 264 NFs randomized into intervention and comparison groups stratified by previous INTERACT use and self reported hospital readmission rates.Intervention: NFs randomized to the intervention group received INTERACT materials, access to online training and a series of training webinars, feedback on hospitalization rates and root cause analysis data, and monthly telephonic support.Measures: Minimum data set (MDS) data for unintentional weight loss, malnutrition, hop fracture, pneumonia, would infection, septicemia, urinary tract infection, and falls with injury for the intervention year and the year prior; unintentional weight loss, dehydration, changes in rates of falls, pressure ulcers, severe pain, and unexpected deaths obtained from the NFs participatin gin the intervention through monthly telephone calls.Results: No adverse effects on resident safety, and no significant differences in safety indicators between intervention and comapriosn gropus NFs were identified with 1 exception. Intervention NFs with high level of INTERACT tool use reported significantly lower rates of sever pain.Conclusions/Implications: Resident safety was not compromised during implementation of a Quality Improvement Program designed to reduce unnecessary hospitalization of NF residents.@2018 AMDA – The Society for Post Acute and Long Term Care Medicine.The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program: An Overview for Medical Directors and Primary Care Clinicians in Long Term Care (full article in the Resource Manual)Joseph G. Ouslander MD, Alice Bonner PhD, GNP, Lauri Herndon MSN, GNP, Jill Shutes GNPAbstractIntervention to Reduce Acute Care Transfers (INTERACT) is a publicly available quality improvement program that focuses on improving the identification, evaluation, and management of acute changes in condition of nursing home residents. Effective implementation has been associated with substantial reductions in hospitalization of nursing home residents. Familiarity with and support of program implementation by medical directors and primary care clinicians in nursing home setting are essential to effectiveness and sustainability of the program over time. In addition to helping nursing homes prevent unnecessary hospitalizations and their related complications and costs, and thereby continuing to be or becoming attractive partners for hospitals, health care systems, managed care plans, and accountable care organizations, effective INTERACT implementation will assist nursing homes in meeting the new requirement for a robust quality assurance performance improvement program which is being rolled out by the federal government over the next year.@2014 – American Medical Directors Association Inc. All rights reserved.WHY TREATMENT PLANNING?Pressure from third-party payors, accrediting agencies and other outside parties has increased the need for clinicians to quicly produce effective, high quality treatment plans. This chapter provides elements necessary to quickly and easily develop formal treatment plans that satisfy the needs of most third-party payors and state and federal agencies>Each Treatment Planner BenefitsSaves you hours of time-consuming paperworkAllows development of customized treatment plansInvolves clear statement describing the behavioral manifestations of each relational problem and include long term goals, short term objectives, and clinically tested treatment optionThis is an easy to use reference format that helps locate treatment plan components by behavioral problem or DSM-5 diagnosis. My aim is to clarify, simplify, and accelerate the treatment planning process, so you spend less time on paperwork, and more time with your clients.ABOUT THE OLDER ADULT PSYCHOTHERAPY TREATMENT PLANNERMuch of the information for this chapter is obtained from the Older Adult Psychotherapy Treatment Planner and comes after 12 years after publication of the first edition. The objectives and therapeutic interventions are evidence based. It is unfortunate that very few students are exposed to aging issues in graduate professional schools since many if not most of now emerging mental health professional will be seeing older adults in clinical practice. A report from the Institute on Medicine raised serious concerns about how the physical health and mental health work forces will serve the needs of the soon to bloom population of older adults (Institute of Medicine, 2008). The reason older adult will part of future clinical practice for many is their sheer numbers: There are 76 million members of the baby boom age cohort. Further it is expected that older adults in the coming years will be more interested in accessing psychotherapeutic services than their parents’ generation when they were older people.The Psychotherapy Treatment Planner offers a practical up to date researched informed set of behavioral definition, long term goals and short term goals, therapeutic interventions and diagnostic consideration that will be helpful for the practitioner who is just beginning his/her career in serving older adults. Readers of this chapter should also consider many excellent texts in the field of aging including those in gerontology, geriatric mental health, and psychotherapy with older adults. Other relevant resources include professional guidelines and consensus statement on mental health practice with older people. This is the beginning of the search for quality care to be a better provider.INCORORATING EVIDENCE-BASED TREATMENT INTO THE TREATMENT PLANEvidence-based or empirically supported treatment (that is, treatment that has shown efficacy is research trials) is rapidly becoming of critical importance to the mental health community as the demand for quality and accountability increase. Indeed, identified empirically supported treatments (e.g. those of the APA Division 12 [Society of Clinical Psychology], the Substance Abuse and Mental Health Servvices Administration’s [SAMHSA] National Registry of Evidence based Programs and Practices [NREPP]) are being referenced by a number of local, state, and federal funding agencies, some of which are beginning to restrict reimbursement for these treatments, as are some managed care and insurance companies.We have made an effort to empirically inform many chapters by highlighting Short-Term Objectives (STOs) and Therapeutic Interventions (Tis) that are consistent with psychological and psychiatric or therapeutic programs that have demonstrated some level of efficacy through empirical study.References to the empirical work supporting these interventions have been included in the reference section as Appendix B. For information related to and limitations of the effort, we suggest the APA Presidential Task Force on Evidence Based Practice (2006): Bruce and Sanderson (2005): Chambless et al (1996, 1998): Chmbless and Ollendick (2001): Catonguay and Beutler (200^): Drake, Merrens, and Lynde (2005): Hofmann and Tompson (2002); and Nathan and Gorman (2007). The AAA guide for care in Long Term Care and Evidence based Resources of Senior PsychCare. Criteria for Inclusion of Evidence-Based TherapiesThe EBTs from which STOs and Tis were taken have different levels of empirical evidence supporting them. For example, some have been well established as efficacious for the problems that they target (e.g. exposure-based therapies for anxiety disorders). Others have less support, but nonetheless have demonstrated efficacy. We have included EBPs the empirical support for which has either been well established or demonstrated at more than a preliminary level as defined by those authors who have undertaken the task of identifying them, such as the APA Division 12 (Society of Clinical Psychology0; Drake and colleagues (2003, 2005); Chambless and colleagues (1996, 1998) and Nathan and Gorman (2007); the APA/AAG.Summary of Required and Preferred EBT Inclusion CriteriaRequiredDemonstration of efficacy through at least one randomized controlled trial with good experimental design, orDemonstration of efficacy through a large, well designed clinical replication series.PreferredEfficacy has been shown by more than one study.Efficacy has been demonstrated by independent research groups.Client characteristics for which the treatment was effective were specified.A clear description of the treatment was available.USE THIS TREATMENT GUIDEUse this Treatment Guide to write treatment plans according to the following progression of six steps:Problem Selection. Although the client may discuss a variety of issues during the assessment, the clinician must determine the most significant problems on which to focus the treatment process. Usually a primary problem will surface, and secondary problems may also be evident. Some other problems may have to be set aside as not urgent enough to require treatment at this time. An effective treatment plan can only deal with a few selected problems or treatment will lose its direction. Choose the presenting issues. What can be treated. What the wants to.Problem Definition. Each client presents with unique nuances as to how a problem behaviorally reveals itself in his or her life. Therefore each problem that is selected for treatment focus requires a specific definition about how it is evidenced in the particular client. The symptom pattern should be associated with diagnostic criteria and codes such as those found in the DSM-5 or the International Classification of diseases.Goal Development. The next step in developing your treatment plan is to set broad goasl for the resolution of the target problem. These statements need not be crafted in measurable terms but can be global procedures. This guide provides several possible goal statement for each problem but on statement is all that is required in a treatment plan (also see setting goals and team capabilities).Objective Construction. In contrast to long-term goals, objectives must be stated in behaviorally measurable language that is clear to review agencies, health maintenance organizations, and managed care organization when the client has achieved the establish objectives. To meet this allows construction of a variety of treatment plan possibilities for the same presenting problem.Intervention Creation. Interventions are the actions to help the client complete the objectives. There should be at least one intervention for every objective. If the client does not accomplish the objective after the initial intervention, new intervention should be added to the plan. Interventions should be selected on the basis of the client’s needs and the treatment provider’s therapeutic plan. We encourage the provider to write other interventions reflecting his or her own training and experience.Some suggested intervention listed refer to specific books that can be assigned to the client for adjunctive bibliotherapy. Appendix A contains a full bibliographic reference list of these materials professionals may wish to consult The Authoritative Guide to Self Help Resources in Mental Health Revised Edition (2003) by Norcross et al. (available from Guilford Press, New York).Diagnosis Determination. The determinataiton of an appropriate diagnosis is based on an evaluation of the client’s complete clinical presentation. The clinician must compare the behavioral, cognitive, emotional , and interpersonal symptos that the client present with the criteria for diagnosis of a mental illness condition as described in DSM-5. Despite arugment made against diagnosising clients in this manner, diagnosis is a reality that exists in the world of mental health care, and it is a necessity for a third party reimbursement. It is the clinician’s thorough knowledge of DSM-5 criteria and a complete iunderstanding of the client assesseemment data that contribut to the most reliable, valid diagnosis ??????? pg 7.After completing these six steps, you should have a comprehensive and individualized treatment plan ready for immediate implementation and presentation to the client.A FINAL NOTE ON TAILORING THE TREATMENT PLAN TO THE CLIENTOne important aspect of effective treatment planning is that each plan should be tailored to the older client’s problems and needs. The individuals strengths and weaknesses, unique stressors, social network, family circumstances and symptom patterns must be considered in developing a treatment strategy. Relying on your own good judgment, clinicians can easily select the statements that are appropriate for the individual whom they are treating. TREATMENT PLANNINGSAMPLE TREATMENT PLANPRIMARY PROBLEM: DEPRESSIONDefinitions; Feeling sad, empty or irritable much of the time. Loss of interest or pleasure in many usual activities. Vegetative symptoms including sleep disturbance, appetite disturbance, weight change, observable motor agitation or retardation.Poor concentration, indecisiveness, impaired memory, or other cognitive symptoms.Fatigue or loss of energy.Difficulty functioning in daily life such as not completing home based tasks or not socially engaging with others.Goals: Reduce or eliminate begatitative symptoms of depression.Increase ability to function in daily life and socially engage with others.Increase feelings of vitality and zest.Learn to identify the early warning signs of a depressed mood and the preventive actions to take.OBJECTIVESINTERVENTIONSConsent to participate in evaluation and treatment.Obtain consent to evaluateAnd treat, including consentTo discuss issues with the Physician(s) and family/staffAs needed.Verbalize in detail depression-related concerns.Ask the client to identify Specific problems with moodBehavior, thoughts/beliefsLife events, interpersonal Issues, and physical plete a self-report assessment to evaluate theAdminister the Geriatric Severity of depression.Depression Scale (Yesavage,Et al, 1983), the CES-DRadloff, 1977), or otherMeasure of depression.Identify whether the symptoms of depression seemAssist the client with identifyingTo be primarily related to interpersonal relationshipsthe primary factors in his/herStressful life events or circumstances, thoughts beliefs.Depression (e.g, disturbed Or behaviors.Interpersonal functioning,Inadequate problem –Solving of stressful events orCircumstances, distorted Thoughts/beliefs, self-Defeating behaviorsCooperate with evaluation and treatment of medicalRefer the client to a Causes of depression.Physician or other medicalProvider for an evaluationOf his/her medical conditionAnd medications (prescribedAnd over the counter) thatCould be contributing toHis/her depression.Cooperate with psychiatric evaluation and pharmaRefer the client to a medicationCological treatment if depression warrants suchprescriber (preferably a Intervention.Geriatric psychiatrist) for an Evaluation and pharmacologicalTreatment if his/her depressionWarrants this.Discuss with the client the Results of the psychiatricEvaluation by the psychiatristOr other prescriber, supportAnd help monitor the planTo treat client’s depressionPharmacologically.Keep a daily record of mood rating from 1 to 10Develop a chart and assignNoting associated behaviors, activities, eventsthe client to record daily mood People and thoughts.Ratings (from 1 to 10) and Record the associated Situations, events, people,Thoughts and behaviors (orAssign Journal of Thoughts)Replace depression-promoting thoughts with moodGently confront unrealisticElevating thoughts.Thinking by suggestingAlternative, logical, positiveThoughts; use role-playing,Modeling, and behavior Rehearsal to have the clientPractice formulating alternativeThoughts in hypothetical Situations.Instruct the client to make aList of all his/her own negative,Self defeating thoughts; assistThe client in replacing eachThought with self-enhancingSelf talk. Identify specific events/activities that elevateHelp determine which currentOr depress mood with ??? and discuss behavioralactivities in daily life the clientRounds and document in progress notes.Considers pleasant and whichHe/she considers unpleasant.Teach the client how behaviorAnd mood are related; un-Pleasant events (or an absenceOf pleasant events) are Associated with low mood;Pleasant events are associatedWith better mood.Systematically increase pleasant events and decreaseTeach the client that his/her Unpleasant events in daily life and consider medicalmood can be improved byAnd social issues that can enhance individualincreasing pleasant events and Decreasing unpleasant events.Encourage the client to identifyPleasant events that areDesirable, but not currentlyPart of a daily routine.Develop a one week dailySchedule with the client thatIncreases pleasant eventsMaking sure to have at leastOne each day.Monitor activities/events andMood through discussion ofDaily mood/behavior recordingProblem-solve and adjust.Monitor and report depressive symptoms, completingAdminister the Geriatric Self-report assessment on a periodic basis.Depression Scale, CES-D, orOther depression reportInstruments on a periodicBasis to quantitatively monitorDepression severity.Develop a plan to sustain recovery from depressiveAsk the client to identifySymptoms.Warning signs of depressionAnd a plan for engaging inBehaviors that will decreaseDepressive symptoms.Help the client to design aHealth promoting lifestyleIncluding attention toExercise, nutrition, substanceUse, social support and Stimulation.DIAGNOSISICD-9-CMICD-10-CMDSM-5 Disorder, Condition, or Problem296.22F32.1Major Depressive Disorder, Single Episode, ModerateACTIVITIES OF DAILY LIVING (ADL/IADL) DEFICITSBEHAVIORAL DEFINITIONSDecline in ability to accomplish one or more basic Activities of Daily Living (ADLs) independently; bathing, dressing, grooming, eating, toileting, mobility/transferring.Decline in ability to accomplish one or more Instrumental Activities of Daily Living (IADLs) independently: shopping, cooking, housekeeping, financial management, transportation, medication management.Confusion or conflict among family, staff, and client about the cause for, or amount of decline in, ADLs/IADLs and associated care requirements.Threat to client’s safety due to decline in ADLs/IADLs, such as falls, malnutrition, adverse drug reactions, or infections.Conflict between expectations for and actual recovery of function after stroke, hip surgery, or other medical event.Client is unwilling or unable to use adaptive equipment to compensate for decreased function.LONG TERM GOALSIdentify cause(s) of decline in ADL/IADL functions and barrier(s) to recovery of function.All involved persons (staff, family, physician, client) reach consensus on cause(s) for disability, prognosis and a care plan.Increase supervision/assistance to enhance safety.Resolve depression and anxiety that may be interfering with motivation to recover function.Maximize capacity for independent functioning in ADL and IADL spheres.Adapt to current and expected level of function.SHORT TERM OBJECTIVES and THERAPEUTIC INTERVENTIONSConsent to participate in evaluation of functional decline if decisionally capable; surrogate consents if the client is not decisionally capable. Obtain consent from the client or surrogate to address the problem of functional decline; include consent to discuss issues with others. Client, staff, and family describe decline in function in specific detail. Explore with the client, staff and family their perspectives on the decline in the client’s function. Administer a structured instrument (eg. Physical Self Maintenance Scale [PSMS, Lawton and Brody]. Rapid Disability Rating Scale [RDRS, Sherwood], the Health Assessment Questionnaire [HAQ, Fried], and the Functional Independence Measure [FTM, Hamilton] to objectively measure the clients’ or others; reports of functional decline.Cooperate with immediate measures to improve safety. Evaluate the client for the possibility of imminent danger to self, such as infections, malnutrition, falls, and/or adverse drug reactions. Arrange for the client’s immediate protection through installation of safety devices addition of services, or in severe cases, transfer to a safer environment.Cooperate with a medical evaluation. Refer the client to a physician for evaluation of medical conditions and medications that could be causing his/her decline in function.Cooperate with psychological evaluation ???? pg 15. Conduct o refer the client for a psychological evaluation to assess possible contributions of depression and/or anxiety to his/her decline in functional ability.Cooperative with neuropsychological valuation. Conduct or refer the client a neuropsychological evaluation to determine if his/her functional decline is associated with cognitive decline. Attend physical therapy evaluation. Refer the client to a professional for an evaluation of his/her mobility related declines in function, such as balance, gait, endurance, ability to transfer and range of motion.Participate in occupational therapy assessment. Refer the client to an occupational therapist for an evaluation of his/her ADLs (e.g. bathing, grooming, hygiene) and IADLs (e.g. driving and cooking)Cooperate with a speech/language evaluation. Refer the client to a speech/language therapist for an evaluation of his/her communication skills and swallowing function.Accept and participate in a referral to a dietician. Refer the client to a dietician for an evaluation of his/her suspected malnutrition.Cooperate with recreational therapy assessment. Refer the client to a recreational therapist for an evaluation of his/her leisure activity function.Client, family, and staff verbalize an understanding of cause(s) for decline in function. Discuss and integrate the results of the client’s evaluations performed by his/her physician and rehabilitation professionals as appropriate. Meet with the client, family, staff, and other professionals as appropriate to give feedback about the nature, severity, scope and causes of the functional decline.Client, family, and staff accept prognosis regarding recovery of function. Explain, or have rehabilitation professional explain, the client’s prognosis for recovery of function. Encourage the client, family, and staff to voice doubts and raise questions about causes/prognosis related to the ADL/IADL decline. Explore with the client and family their emotional reactions to evaluations including denial, grief, feelings of hope or hopelessness, anger, and related feelings.Client family and staff agree on care plan to improve function as much as possible. Introduce the concept of excess disability to the client and family, explaining that often negative psychological or environment factors produce disability beyond that which is expected from physical or cognitive causes; by addressing the causes of excess disability, the client’s function can often improve. Establish with the client and family what functions might be improved through addressing psychological or environmental factors. Establish with the client, family, and rehabilitation professionals what functions might be improved through a formal rehabilitation program. Propose and obtain client and family agreement to a care plan for the client that combines all relevant modalities, professionals and family ply with recommendations to change medications, dosage, or scheduling to improve function and federal and state guidelines. Reinforce the physician’s recommendations regarding the client’s medication and other treatments that could positiviley impact his/her ADl/IADL function.Cooperate with treatment for confounding or coexisting depression and anxiety. Address the client’s psychological components of excess ply with treatment for rehabilitation of function. Motivate the client to comply with rehabilitation treatment, providing an outlet for ventilation of frustration, but also providing encouragement for reinforcement for completed sessions. Communicate regularly with rehabilitation professional regarding the client’s goals, progress and psychological status.Use adaptive equipment that can compensate for decreased function. Provide follow up and encouragement for rehabilitation professional’s recommendations regarding adaptive devices for the ply with rehabilitation recommendations for ongoing changes in lifestyle and need for increased assistance with ADLS/IADLs Provide follow up and monitoring for rehabilitation professional recommendations regarding the client’s lifestyle changes. Verbalize and document an acceptance of increased level of supervision to necessary to assure safety or to compensate for decreased independent functioning. Provide an emotional outlet for the client to discuss ambivalence toward, and conflict with caregivers. Help the client resolve conflicts with the caregivers and adapt to greater dependency.Identify activities that can be performed as substitutes for those activities that cannot be performed. Have the client, family, and caregivers identify all areas of preserved function. Work with client, family , and caregivers to identify substitute activities for those that can no longer be performed such as winding yarn in place of knitting. Assist the client in finding alternative sources of self esteem; for example, even if arthritic hands cant’ perform old task, they can be beautifully manicured. Reminisce about former accomplishments and relationship that built self esteem. Use reminiscence to identify and elevate the client’s lifelong sources of self esteem. Teach caregivers to encourage reminiscence through berbal description of events and people, looking at photographs, playing music from earlier eras, and/or handling object from earlier eras.DIAGNOSTIC SUGGESTIONSICD-9-CMICD-10-CMDSM-5 Disorder, Condition, or Problem294.10F02.80Probable Major Neurocognitive Disorder DueTo Alzheimer’s Disease, Without BehavioralDisturbance.294.10F02.81Probable Major Neurocogntive Disorder DueTo Alzheimer’s Disease with BehavioralDisturbance.290.4F01.50Probable Major Vascular Neurocognitive Disorder Without Behavioral Disturbance290.4F01.51Probable Major Vascular NeurocognitiveDisorder, With Behavioral Disturbance294.9R41.9Unspecified Neurocognitive Disorder296.xxF32.xMajor Depressive Disorder Single Episode296.xxF33.xMajor Depressive Disorder Recurrent Episode309.9F43.20Unspecified Adjustment Disorder293.84F06.4Anxiety Disorder Due to Another MedicalCondition316F54Psychological Factors Affecting Other MedicalConditionsANXIETYBEHAVIORAL DEFINITIONSExcessive fear and worry about life and health circumstances.Inability to control worries about health, family members, social relationships, volunteer or job responsibilities.Fear, worry, and other symptoms cause social withdrawal and sleeplessness.Fear, worry, and other symptoms significantly interfere with daily functioning ina variety of situations.Autonomic hyperactivity such a palpitations, chest pain, shortness of breath, sweaty palms, dry mouth trouble swallowing, nausea or diarrhea.Motor tension, such as restlessness, fatigue, trembling or shakiness.Altered cognition, such as difficulty concentrating, mind going blank, feeling of unreality, or feeling of being detached from oneself.Hypervigilance such as feeling constantly on edge, sleep disturbance, and irritability.Development of a dependence on substances to control anxiety symptoms.Subjective symptoms use SOAP format.LONG TERM GOALSSignificantly reduce the overall frequency and intensity of the anxiety symptoms so that daily functioning is improved.Decrease worry and fearful thoughts and increase optimistic, problem solving thoughts.End substance abuse as a means of escaping anxiety and increase constructive coping behaviors; learn stress management skills to prevent anxiety response.Learn cognitive and behavioral skills to resolve anxiety producing problems.Manage environmental stressors in a way to reduce psychological pressure.Utilize exposure to reduce reactivity to situations that trigger anxiety.SHORT TERM OBJECTIVES and THERAPEUTIC INTERVENTIONS List of all prescribed and over the counter medications, dosage, and time of day they are taken. Ask the client to produce a list of all prescribed and over the counter medications, dosages, and time of day they are taken; if the client is unable to complete this task, ask that all medication containers be brought to the next session.Family members should be contacted if necessary. Discuss with the team the necessity of working with the primary care physician to determine if there may be a biological etiology to the anxiety symptoms. The long term care staff should designate family members in treatment.Accept referral to psychiatrist to review possible relationship between anxiety symptoms, illnesses, and medications. Discuss with physician ordered changes in medications, dosages, or administration schedules to alleviate anxiety symptoms in behavioral rounds. Obtain from physician the ordered changes in medication, dosages, or administration schedules to reinforce the client’s compliance with the changes.In behavioral rounds and huddles discuss with the staff an understanding of the general physical and cognitive manifestations of the causes for anxiety. Discuss with the staff the client anxiety symptoms clusters and how the client’s symptoms falling to one or more cluster; autonomic, cognitive, and hypervigilant. Discuss with the client the possible etiologies of these symptoms; Illness.Identify the specific anxiety symptoms that are personally most disturbing or most contributing to impaired functioning. Assign the client to verbalize or list all specific anxiety symptoms in detail and to rank order the symptoms on the basis of how disturbing they are. Help the client ot identify whether and/or how each symptoms interferes with daily functioning and/or relationships.If resources are available a daily journal of anxiety symptoms for one week to establish frequency, intensity, time of day, and duration of the symptoms. Keep a daily journal of anxiety symptoms. Assign the client and long term care staff and family to gather specified data on anxiety symptoms for one week through daily recording of symptoms, occurrence, time of day, intensity (rating 1 to 10) and duration of symptoms. It may help to assign the completion of a simple chart for the client to daily record the frequency and intensity (rated 1 to 10) of anxiety symptoms and to record the precipitating and consequent situation, events, people, thoughts, moods, and behaviors that are associated with anxiety symptoms. Identify and clarify the patterns of anxiety precipitants and consequences. While reviewing the client’s anxiety symptoms chart, help him/her recognize patterns associated with anxiety symptoms; sort of precipitants from consequences, identify the most intense or frequent precipitants, and identify the consequences that help to perpetuate maladaptive patterns. List the negative consequences of anxiety symptoms and identify the highest priorities for change. Assist the client in listing the negative functional consequences of anxiety. List the current attempts to cope with anxiety symptoms that have long term negative effects. Assist the client in identifying his/her current attempts to reduce anxiety, their apparent positive consequences, but longer term negative consequences. Identify specific stimulus situations, events, or people that precipitate anxiety symptoms. Review the client’s chart of anxiety symptoms and their precipitants and consequences to help the client identify specific stimulus situation or pole that precipitate anxiety symptoms. Minimize situations that produce anxiety and in which avoidance doesn’t have long term negative consequences. Help the client determine which situations, events, and people can be constructively avoided.Use assertiveness to deal constructively with situations that needs to be confronted to reduce anxiety. Help the client determine which situation, events, and people can be assertively changed to alleviate anxietyIdentify daily routine activities that have been effective in reducing anxiety in the past. Assist the client in identifying the most effective personal stress management techniques and encourage daily scheduling of these activities. Make lifestyle changes in diet, exercise, and pleasurable habits that will reduce anxiety symptoms. Have long term care staff review healthy lifestyle issues with client.Have psychotherapists help learn and practice thought and behavioral control methods to minimize and control anxiety symptoms once they have begun. Help the client develop a plan of action for specific anxiety situations using behavioral control and cognitive control. Have psychotherapists identify specific thoughts that precipitate anxiety symptoms. Review the client chart of anxiety symptoms and their precipitants to assist client in identifying and clarifying thoughts that precipitate anxiety response. Discuss with the client the extent to which the thoughts reflect a realistic situational appraisal versus an overly negative or catastrophic situational appraisal; facilitate separation of the relational core concern from the exaggerated irrational thoughts that generate an excessively and debilitating emotional response.At behavioral rounds verbalize a plan to reasonably address the rational concerns that generate some anxiety. Replace anxiety producing thoughts with constructive thoughts. Assign the client the task of developing a plan to address the relational core concerns by changing things that are under client control and accepting things that cannot be changed. Challenge thoughts that transform rational concerns into overwhelming and/or unresolvable conflict; help thte client to identify and challenge anxiety producing, negative self talk, assign homework to practice identification of such thoughts, and replacement with constructive thoughts.The psychotherapist should use cognitive methods to control anxiety symptoms. Practice and implement relaxation techniques to reduce anxiety. Undergo gradual repeated exposure to the feared negative consequence predicted by irrational worries and develop reality based predictions. Assist the in in developing soothing, positive self talk that effectively de escalates the anxiety response. Teach the client relaxation techniques, beginning with deep breathing and proceeding to progressive muscle relaxation and guided imagery to enhance relaxation; provde the client with a personalized audiotape and suggest the purchase of a relaxation audio or videotape if he/she owns relevant equipment. Assign the client to read about “worry exposure’ in books or treatment manual of the treatment of worry and anxiety. Direct and assist the client in constructing a hierarchy of two to three spheres of worry for use in exposure. Ask the client to vividly imagine worst case consequences of worries holding them in mind until anxiety assocated with them weakens; generate reality based alternative to that worst case and process themEvalute realistically the need for additional emotional suppor fromothers and help in performing activites of daily living. Help the client to determine if additional help is need to accomplish the Activates of Daily Living or Instrumental Activates of Daily Living; develop a plan to obtain such support to reduce worries about personal inadequacies. Discuss the client’s willingness to involve an informal support network in providing additional support and additional concrete care and services; develop a plan to ask for help.Monitor the client’s anxiety to determine if the additional of interpersonal support and ADL and IADL services decreased anxiety Different diagnosis cooperate with a substance abuse evaluation to determine the extent of chemical dependence. Evaluate and treat the client for substance abuse/dependency and misuse. Adjust living situation to reduce environmentally induced stress. Teach the client the concept of finding a good match between the individual’s capacities and the demands of the physical environment. If the physical environment is too demanding for the individual’s capacities, the individual can become overwhelmed and may need to move from large home to smaller accommodations. Help the client to determine if the current living situation is appropriate to the client’s capacity or if a change is warranted given the current or anticipated capacity. Assist the client with psychological components of making a change in the living situation.DIAGNOSTIC SUGGESTIONSICD-9-CMICD-10-CMDSM-5 Disorder, Condition or Problem308.3F43.0Acute Stress Disorder300.02F41.1Generalized Anxiety Disorder283.84F06.4Anxiety Disorder Due to AnotherMedical Condition309.24F43.22Adjustment Disorder with Anxiety300.00F41.9Unspecified Anxiety DisorderDECISIONAL INCAPACITYBEHAVIORAL DEFINITIONSA disturbance of consciousness such that the client appears unable to comprehend decisional issues. Dementia or delirium causes a disturbance in cognitive abilities such as executive functioning related to decision making capacity.A psychotic process results in impaired judgement, illogical thinking, and disturbance of perception.A serious emotional condition compromises decisional capacity.Unable to fully participate in specific decision regarding medical care such as managing health, appointing health care proxy, consenting to accept/withdraw/withhold medical treatment, or executing advance directives.Unable to fully participate in specific decisions regarding legal affairs such as writing or changing a will, or designating a power of attorney.Unable to fully participate in specific decisions regarding financial affairs such as withdrawing money from an account, changing beneficiaries, selling property, or donating money.Unable to fully participate in specific decisions regarding residential affairs such as deciding whether to live alone versus in a more supervised setting.Unable to fully participate in decisions related to consent to sexual relations.Appears to be under undue influence of others who do not have client’s best interests in mind.Conflict among individual, family, caregivers, and/or health care provider about care decisions.Request from family, physician, lawyer, or court for help in determing the client’s capacity to appropriately participate in specific decisions.LONG TERM GOALSExercise the right to make future decisions through the execution of advance directives.Maximize the client’s capacity to consent to relevant issues.Protect the decisionally impaired client so that he or she involves others who have his or her best interests in mind.Reduce or eliminate conflict among involved parties when decisions and decision making capacity are unresolved.DISTRUBTIVE BEHAVIORS OF DEMENTIABEHAVIORAL DEFINITIONSVerbal and vocal behaviors that are disruptive to others such as moaning, repetitive requests, repetition of words, phrases, or questions or nonsensical verbalizations.Verbally aggressive behavior such as cursing or screaming at others or threatening to harm them.Acting physically aggressive toward others including hitting, biting, or kicking.Pacing or inappropriately handling objects.Refusing personal care.Nocturnal wandering and other sleep disturbances.LONG TERM GOALSReduction in frequency and intensity of disruptive verbal behaviors.Reduction in frequency and intensity of physical and verbal aggression.Reduction in frequency of nocturnal wandering and improvement of sleep pattern.Perform personal care tasks on a regular basis.Improved quality of life and safety for client including participation in pleasurable events and activities with concurrent improvement in mood.Enhanced ability of family and profession caregivers to provide assistance to the client.SHORT TERM OBJECTIVES and THERAPUETIC INTERVENTIONSReengage, Redirect, Respect, and RestrictConsent to participate in evaluation of disruptive behaviors if decisionally capable; surrogate consents if the client is not decisionally capable. Obtain consent from the client or surrogate to address problematic disruptive behaviors.Cooperate with the implementation of necessary safety precautions to protect self and others from harm. Evaluate danger to the client and others; take immediate safety precautions.Cooperate with an evaluation to identify medical, neurological, and/or psychological causative factors of disruptive behaviors. Refer the client to a physician for an evaluation of medical conditions and medications that could cause or exacerbate disruptive behaviors. Conduct or refer the client for a psychological evaluation to assess possible contribution of depression, anxiety, or other psychological factors to disruptive behaviors. Conduct or refer the client for a neuropsychological evaluation and to a neurologist for a neurological exam to determine if his/her disruptive behaviors are caused by a brain disorder or progression of brain disorder.INTERPERSONAL DISPUTESBEHAVIORAL DEFINITIONS *see worksheet for decision making capacity in Resource ManualFrequent arguing with spouse, adult children, siblings, caregivers.Angry blaming of others because of interpersonal disputes.Engaging in or receiving physical or emotional abuse.Emotional withdrawal from significant others because of unresolved conflict.Refusing to speak to, or reducing contact with, significant others.Considering separation or divorce from spouse or partner. A pattern of repeated conflict and dissatisfaction with many individuals.Refusal to cooperate with or firing professional caregivers. LONG TERM GOALSResolve current disputes with significant others and establish more mutually satisfying relationships.Terminate relationships as appropriately necessary.Eliminate physically or verbally abusive behavior.Understand how interpersonal behavior contributes to relationship disputes.Develop an understanding of how depression can be a cause or consequence of interpersonal disputes.Learn communication and related skills to prevent or resolve interpersonal disputes.SHORT TERM OBJECTIVES AND THERAPEUTIC INTERVENTIONS.Verbalize the specific problems in the current dispute, stating the differences between what self and other(s) want. Ask the client to identify problems in the current conflictual situation. What are the issues? How long standing is the conflict? What efforts have been made to resolve the dispute and with what results? Ask the client to clarify differences in expectations and values between self and other that contribute to the dispute.Disclose whether physical abuse is occurring in the conflicted relationship. Ask the client if disputes have involved physical abuse. Discuss with the client if abuse is associated with risk to physical well being of the client or others. Discuss with the client a safety plan to reduce likelihood of harm to self or others. Advice the abused client that elder abuse must be reported to adult protective services.Acknowledge whether the dispute was preceded by the onset of depression or whether depression followed the development of the dispute. Accept a referral for a medication evaluation. Identify what is lost and what is gained by continuing the conflict. Assist the client in assessing if depressive symptoms were evident prior to the conflict and contributed to it, developed after the conflict and resulted from it, or both. Educate the client that depression can lead to interpersonal tensions and/or that interpersonal disputes often result in depression. Refer the client for evaluation of the need for antidepressant medication. Explore the meaning of the conflict and for other(s). Who gains what from the conflict. What is lost by continuring the conflict?Clarify beliefs about whether change is possible in the relationship. Explore with the client the likelihood that the relationship can be improved and what would be needed to change it.Specify what changes are desired in the relationship. Make a commitment to change own behavior in current interpersonal disputes. Explore with the client what would need to change to make it more satisfying. Explore with the client whether the identified interpersonal problem is evident in other relationships. Explore the client’ willingness to change his/her own expectations or behavior to arrive at a resolution to the dispute and the client’s perception of what the other person needs to change. Educate the client that psychotherapy is an opportunity to try new ways of thinking about and behaving in, relationships.LONELINESS/INTERPERSONAL DEFICITSBEHAVIORAL DEFINITIONSComplaints of loneliness, being all alone, being ignored by family members, having no plaints of being unable to make friends in a new setting or residence.Expressions of frustrations or anger that others do not care about or like the client.Depressed mood associate with inadequate social connections.History of inadequate interpersonal relationship in adulthood.Keeps self socially isolated in adult day care, senior center, or residence.Family expresses concern that client ins socially isolated.Lack of social network to provide support t during difficult life transition as such as retirement, post hospital care, death of a loved one, or relocation.LONG TERM GOALSDecrease social isolations.Increase available social network.Resolve depression associated with inadequate social relationships.Learn skills for forming and maintaining new friendships.Learn skills for reviving, sustaining, and /or renegotiating family and friend relationships.Learn skills for seeking and maintaining supportive relationships based on mutual need.SHORT TERM OBJECTIVES AND THERAPEUTIC INTERVENTIONSDescribe current relationships with family, friends, acquaintances, and others, Describe significant past relationships with others. Assess whether limited relationships are associated with depression. Ask the client about the nature of current interactions, expectations about current relationship and their fulfillment or lack of fulfillment, satisfaction/dissatisfaction with current relationship and what the client would like to be different. Ask the client about the nature of past relationship interaction, expectations about tpast relationships and their fulfillment or lack of fulfillment, satisfaction/dissatisfactions with past relationships, and what the client would like to have been different.MANIA/HYPOMANIABEHAVIORAL DEFINITIONSExhibits a loud, overly friendly social style that oversteps social boundaries and shows poor social judgement.Displays an inflated sense of self-esteem and an exaggerated, euphoric belief in capabilities that denies any self-limitations; others are seen as obstacles standing in the way.Reports racing thought or flight of ideas.Exhibit high energy, restlessness, and pressured speech.Has positive personal and/or family history of affective disorder.Evidences verbal and/or physical aggression if whishes are blocked or if requested to comply with policies and procedures considered undesirable.Shows evidence o a poor attention span and susceptibility to distraction.Engaged in impulsive behaviors that reflect a lack of recognition of self-defeating consequencesEngages in bizarre dress and/or grooming. LONG TERM GOALSEliminate verbal and/or physical aggression.Increase control over impulses, flighty thinking, and pressured speech.Reduce energy level and reestablish appropriate sleep wake cycle.Reduce elevated mood and prevent onset of depression.Improve social judgment and social interactions.Reestablish positive relationships with family members, friends, caregivers and those in residential environment.Accept the need for continued treatment and comply with medications and psychotherapy on a long term basis.SHORT TERM OBJECTIVES AND THERAPEUTIC INTERVENTIONSCooperate with necessary safety precautions to protect self and others from harm. Evaluate severity of danger to self and others: take immediate safety precautions as needed.Describe mood state, energy level, and amount of control over thoughts, and sleeping patterns. Assess the client for signs of mania; pressured speech, impulsive behaviors, euphoric mood, flight of ideas, reduced need for sleep, inflated self esteem, and high energy; utilize family or caregivers observations of the client’s behaviors, as needed.Cooperate with psychiatric evaluation as to the need for medication and/or hospitalization to stabilize mood and energy. Arrange for hospitalization if the client is judged to be potentially harmful to self or others, or is unable to care for his/her own basic needs and does not have available needed caregivers. Arrange for psychiatric evaluation of the client for pharmacotherapy.Achieve a level of symptom stability that allows for meaningful participation in psychotherapy. Complete psychological testing to assess communication patterns within the family Monitor the client’s symptom improvement so that his/her condition is sufficiently stabilized so as to allow participation in psychotherapy. Conduct or arrange for administration of an objective assessment instrument for evaluating family communication pattern, particularly expressed emotion.PARANOID IDEATIONBEHAVIORAL DEFINITIONSStatement of erroneous beliefs involving a misinterpretation of perceptions or experiences.Statements that one is being persecuted, tormented, stolen from, poisoned, or spied on.Erroneous statements that general environmental cues are directed at self – that casual gestures, comments, and/or laughing of others are all directed at plaints that people are talking about self in the absence of any conversations.Refusal to allow home health, meal delivery, or repair services in the home because of irrational fear or harm to self.Activity taken to protect oneself from harm in the absence of an actual threat.Withdrawal from social interaction and refusal to participate in activity programs due to verbalized irrational suspicions.Overt signs of inexplicable hostility and extreme irritability toward others.Unexplained measure that break off ties with relatives such as refusing phone calls, visits, removing them as estate beneficiaries.LONG TERM GOALSTerminate danger to self or others.Develop trust in at least one other person.Reduce or eliminate erroneous irrational suspicious beliefs.Reduce or eliminate hostility and irritability exhibited toward others.Reduce or eliminate feelings of fear and insecurity.Cooperate with necessary and desirable medical, social, and home services.SHORT TERM OBJECTIVES AND THERAPUETIC INTERVENTIONSConsent to participate in a psychiatric evaluation if decisionally capable; surrogate consents if the client is not decisionally capable. Obtain consent from the client or surrogate to address the problem of paranoid ideation including consent to discuss issues with other involved parties. Evaluate or refer the client to a physician for an evaluation of the severity of danger to self and others; drop by or telephone the client every day to a 2- to5- minute contact, allowing him/her to determine the content of conversation or activity.Tolerate a 20- minute non threatening session with the therapist. Gradually increase contact time with the client to 20 minutes face to face, continuing to allow him/her to determine the content of the conversation or activity.Tolerate a 30 minute non threatening session with the therapist. Increase counseling session contact time to 30 minutes face to face with the client determining the content of the conversation or activity.Verbalize personal concern to the therapist as a manifestation of trust. Gently begin introducing topics that seem to be anxiety producing for the client as tolerated. Reduce the client’s anxiety with a reassuring, calm, gentle, rational manner providing practical help, problem solving, and advocacy.Cooperate with a psychological assessment. Comply with a neuropsychological evaluation. Conduct or refer the client for a Psychological evaluation to determine the psychiatric and functional history, onset of problem, precipitants, and psychosocial stressors that could be prompting or contributing to paranoids ideation. Conduct or refer the client for a neuropsychological evaluation to determine if his/her cognitive status could be causing or contributing to paranoid ideation.PERSISTENT PAINBEHAVIORAL DEFINITIONSExperience feelings of persistent pain in one or more parts of the body that are attributed to current medical condition(s).Reports generalized pain in many parts of the body such as joints, muscles, and bones.Experience of pain results in decrease in completion of daily responsibilities, lessend physical activity, and/or reduction in social involvements.Caregivers of older adult with dementia report pain related behavior in older adult such as grimacing, moaning, rocking, exhibiting protective gestures associated with likely locus of pain, crying, or irritability.Experiences increasing symptoms of depression as pain persists and/or increases in intensity.Has become more and more reliant of narcotic, pain relieving medication to cope with the discomfort. LONG TERM GOALSExperience decreased feelings of intensity and/or duration of pain episodes.Obtain needed skills to better manage pain.Better cope with pain to increase ability to complete daily responsibilities and engage in social activities.Experience decreased feelings of depression associate with pain.Find a new sense of empowerment in ability to manage pain.SHORT TERM OBJECTIVES AND THERAPEUTIC INTERVENTIONSIdentify history and nature of persistent pain. Identify the impact of persistent pain on daily life. Cooperate with assessment of the mental health impact of persistent pain. (refer to SPC Protocols on Pain Management. SPC does not prescribe narcotics). Ask the client to describe the frequency, duration, bodily location, and intensity of pain experiences. Assign the client to complete a pain intensity scale such as a pain thermometer or facial representation of pain measure. For clients with dementia, ask professional caregivers to evaluate behavioral symptoms of pain using a standardized measure such as the Pain Assessment Checklist for Seniors with Limited Ability to Communicate. Help the client ot identify events that appear to precede the onset of pain episode and those factors that alleviate the experience of pain Request that the client verbalize knowledge and attitudes toward pain and its treatment; assign client bibiotherapy resources such as Pain Management for Older Adults: A Self-Help Guide.RESIDENTIAL ISSUES UNRESOLVEDBEHAVIORAL DEFINITIONSInability to manage daily activities required ot maintain household because of physical and/or cognitive impairments.Emotional distress caused by feelings of being overwhelmed by household management.Living in the current residence poses danger to self or others because of fire hazards, physical or cognitive impairment, malnutrition, infestations, crime victimization, or abuse.Family conflict regarding what is an appropriate living situation.Inability to initiate the process of moving, in spite of decision to do so .Grief associated with loss of home.Financial inability to maintain household.Loneliness and social isolation associated with current residence. LONG TERM GOALSMatch residential environment to physical, emotional, and cognitive needs and abilities.Resolve emotional issues associated with residence, such as grief if a move is required, loss of independence and privacy if household help is added.Resolve family conflict regarding residential status.Ensure safe and comfortable residential environment.Ensure adequate socialization opportunities within or outside of the home.Maximize financial status through the use of creative home financing mechanism and the use of available senior services.SHORT TERM OBJECTIVES AND THERAPUETIC INTERVENTIONSVerbalize distress about the current living situation. Explore the client’s feelings of fear associated with the current or future residence. Encourage the client to confront the difficult issues of an appropriate residence head on and thereby stay in control of the decision making. Reassure the client that when the living environment matches his/her needs, abilities and preferences, distress will decrease and life satisfaction will return. Verbalize an understanding of the residential services and living options available. Educate the client about he continuum of elder housing/service options available; in home services, adult day services, active adult retirement living, senior apartment living, assisted living, nursing home, and continuing care retirement community. Explain to the client without too much detail at first, that some creative financing options are available for those who want to remain in their homes such as reverse mortgages.Make a commitment to participate in, and cooperate with, the problem solving process. Give consent for the therapist to contact family members, physicians, lawyer, social services, and gaining agencies as needed. Ask the client to make a commitment to work on resolving the questions about eh living situation and the associated emotional issues. Discuss with the client the desirability of involving all interested parties in the decision making process: ask for consent to contact particular individual as necessary. Discuss parameters of privacy and confidentiality. Identify environmental characteristics of current residence that are problematic. Acknowledge cognitive functioning deficits that contribute to danger in the current living situation. Identify the emotional factors that make change in residence very difficult. Assist the client in identifying aspects of current residence that contribute to problems living in it. Help the client to identify his/her cognitive impairment related issues that contribute to the housing problem. Explore the emotional issues that keep the client from making an objective decision about housing and supervision needs.State the financial concerns that are exerting an influence on the housing decision. Help the client identify financial worries that are involved in the decision regarding residence.Identify the family dynamics that cause conflicts about residential decision making. Explore the family dynamics that influence decision regarding the living situation.Verbalize any problems that cannot be sufficiently addressed in the current residence. Verbalize acceptance of the necessity for alternative housing. Gather information from family members regarding alternative housing. Work with the client to determine if problems related to physical limitations, cognitive deficits, safety factors, and finances can be sufficiently resolved within the current residence.Family members reach consensus on a written plan regarding residence, finances, and contact; specify who is responsible for what action at what time. Encourage the family to wirte out an agreed upon plan to provide emotional, social and financial support to the clients’ residential plan; be specific to prevent tension among sibling in the future.Implement a residential plan verbalizing emotional reactions during the process while asking for and accepting support as necessary. Support the client in the implementation of the residential plan; monitor and process his/her emotional reactions during the process; adapt the plan as necessary; and encourage the client to continue asking for support as necessary.SEXUALLY INAPPROPRIATE BEHAVIOR (See also Too Close for Comfort)BEHAVIORAL DEFINITIONSGrabbing, fondling, or holding the breasts or genitals of staff person providing personal careUnwelcome sexual remarks to staff person(s).Masturbation in public areas.Urinating into inappropriate containers (such as plants or radiators) or on the floor.Undressing in public areas.Fondling or touching the genitals of unsuspecting persons.LONG TERM GOALSReduce intensity and frequency of sexually inappropriate behaviors.Reduce stimuli or triggers of inappropriate sexual behaviors in the environment.Increase stimuli or triggers for appropriate sexual behavior in private areas.Staff/family caregivers improve capacity for managing sexually inappropriate behaviors and gently redirecting.SHORT TERM OBJECTIVES AND THERAPEUTIC INTERVENTIONSConsent to participate in an evaluation of inappropriate sexual behavior if decisionally capable; surrogate consents if the client is not decisionally capable. Obtain consent from the client or surrogate to address the problem of inappropriate sexual behavior including consent to discuss issues with other involved parties.Cooperate with an evaluation to identify medical, neuropsychological, and/or psychological causative factors of the inappropriate sexual behavior. Conduct or refer the client for a psychological evaluation to assess possible contributions of depression, anxiety, substance use, premorbid personality or coping styles to inappropriate sexual behavior.Agree to a treatment plan for confounding or coexisting depression, anxiety, medical conditions, and/or adverse drug reactions. Cooperate with an evaluation to identify the specific behavioral pattern if any of the sexually inappropriate behaviors. Discuss the results of the evaluations with the client, family, physician, other healthcare providers, and staff as appropriate; d develop a plan to address treatable medical and psychological causes for the behavior. Teach the caregivers to keep behavioral records establishing at least one week of baseline recording of the sexually inappropriate behavior or longer if the episodes are infrequent. Long term care staff to create a chart for caregivers to record baseline data; provide instruction on, and rationale for, proper recording of data. Conduct behavioral analysis gathering detailed data on the frequency of the episodes, time of day, location, precipitants, specific behavior, consequences and who was present. Caregiver identifies possible antecedents to the client’s inappropriate sexual behavior. Analyze with the caregivers the behavioral patterns and develop hypotheses about possible triggers to inappropriate sexual behavior. Analyze with the caregivers the early warning signs of inappropriate sexual behavior, if any. Teach the caregivers to ensure the safety and dignity of the client, themselves, and others by reacting to sexually inappropriate behavior with clear limits, but no harshly or critically, remove the client from the environment if necessary.Satisfy tacticle needs and bodily functions in an appropriate manner. Teach the caregivers to address the client’s physical needs (e.g. toileting regularly, providing appropriate tactile stimulation such as holding hands or holding a comforting object).Report feeling more accepted and attended to. Teach the caregivers to address the client’s emotional needs (e.g. spending at least five minutes talking to the client, reassuring the client that he/she is accepted).Terminate inappropriate sexual behavior during personal care. Teach the caregivers to avoid overstimulating the client during personal care, try a different caregiver. Express sexual and affectional needs in an appropriate manner with a willing partner. Explore with the staff/family desires and opportunities for appropriate sexual expression such as conjugal visits with a spouse or partner and/or appropriately expressed affection between residents. Explain to the family and staff the complexity of decision making regarding sexuality when the client is cognitively impaired.Engage in non sexual but mutually pleasurable and satisfying activity with the caregiver. Assign the client and caregivers to develop a list of mutually satisfying pleasurable activities (e.g. looking at old photographs, grooming hair and nails, feeding birds.)DIAGNOSTIC SUGGESTIONSICD-9-CMICD-10-CMDSM-5 Disorder, Condition, or Problem293.0F05Delirium Due to Another Medical Condition293.0F05Delirium Due to Multiple Etiologies294.10F02.80Major Neurocognitive Disorder Due to AnotherMedical Condition Without Behavioral Disturbance290.4F01.50Probable Major Vascular Neurocognitive Disorder,With Behavioral Disturbance294.8F06.8Other Specified Mental Disorder Due to AnotherMedical Condition294.9R41.9Unspecified Neurocognitive Disorder995.2F19.988Other (or Unknown) Substance Induced Neurocognitive DisorderSUICIDAL IDEATION/BEHAVIORBEHAVIORAL DEFINITIONSRecurrent thoughts of, or preoccupation with, taking one’s own life.Recurrent thoughts of, or preoccupation with, a passive wish to die.Persistent or recurring suicidal ideation without any plans.Persistent or recurring suicidal ideation with a specific plan.Recent significant weight loss due to low caloric intake.Refusal to take in enough nutrition and hydration to maintain weight and fluid requirements, when physically and cognitively capable of doing so.Persistent expressions of being a burden to the family, hopelessness, having no meaning or purpose in life, having no quality of life, and/or being in constant physical pain.Recent suicide attempt or history of suicide attempts.Evidence of access to means of committing suicide (e.g. weapons, pills)Significant withdrawal from social activities or a decline in Activities of Daily Living (ADL) and/or Instrumental Activities of Daily Living (IADL) functions. LONG TERM GOALSStabilize suicidal crisis.Alleviate suicidal impulses/ideation and return to highest level of previous ADL and IADL functioning.Obtain appropriate pain management to reduce feelings of hopelessness.Develop adaptive mechanisms for coping with negative feelings and life events.Resolve issue of feeling like a burden to family members.Develop a satisfying quality of life that results in a sense of hopefulness, meaning, and purpose.SHORT TERM OBJECTIVES AND THERAPEUTIC INTERVENTIONSComply with a suicide prevention procedure of relinquishing potentially dangerous materials such as weapons or hoarded medications. Direct the client, or instruct caregivers to direct the client, to relinquish materials that could be used to commit suicide. Explain to the client that professional practice laws require that the therapist act to protect the client from harm to self or others.Agree to the presence of another person until suicidal threat resolves. Stay with the client or arrange for a family member or caregiver to stay with the client until the threat of imminent harm has passed.Verbalize specific suicidal thoughts, feelings, plans, and actions. Assess the severity of the suicidal ideation by asking the client to share suicidal history, feelings, thoughts, plans, and behaviors. Distinguish carefully between thoughts of death that are appropriate, wishing to die that may be disease-state-specific, and suicidal ideation that may be a sign of underlying depression that requires treatment. Assess whether the suicidal ideation/behavior is active or passive.Cooperate with psychological testing to assess suicidal risk and depth of depression. Arrange for administration of Geriatric Depression Scale, the CES-D, or other objective assessment instruments; evaluate the results and give feedback to the client.Cooperate with a clinical interview to determine the necessity for a more intensive site of service or more intensive services at the current site. Arrange for transfer of the client to a more intensive care site if the client has not resolved the suicidal crisis.Agree to level of care necessary to protect from suicidal impulses; verbalize an understanding that if danger to self persists, involuntary care will be pursued. Comply with psychopharmacological medication regimen as prescribed. Arrange for provider to examine the client to assess suicidal ideation/behavior, order psychotropic medications as indicated, titrate medications, and monitor side effects.Develop an action plan to carry out the chosen method of coping with the problematic situation. Discuss with the client the actual steps he/she would need to take or ask others to take, that would begin the problem resolution process. Encourage the client to take needed actions to move toward problem resolutions.DIAGNOSTIC SUGGESTIONSICD-9-CMICD-10-CMDSM-5 Disorder, Condition, or Problem291.81F10.24Alcohol-Induced Depression Disorder, UseDisorder Moderate or Severe292.84F13.24Sedative, Hypnotic, or Anxiolytic-InducedDepressive Disorder, Use Disorder ModerateOr Severe296.xxF32.xMajor Depressive Disorder Single Episode296.xxF32.xMajor Depressive Disorder Recurrent Episode300.4F34.1Persistent Depressive Disorder309.9F43.20Unspecified Adjustment Disorder316F54Psychological Factors Affecting Other MedicalConditions301.83F60.3Borderline Personality DisorderBIBLIOTHERAPY SUGGESTIONS FOR CHAPTER 9Activities of Daily Living (ADL/IADL) DeficitsLorig, K., Holman, H. Sobel, D., Laurent D., Gonzalez V., & Minor, M. (2006). Living a healthy life with chronic conditions: Self-management of heart disease, arthritis, diabetes, asthma, bronchitis, emphysema and others (3rd ed.). Boulder, CO: Bull Publishing Company.Tholen, J. F. (2008). Winning the disability challenge: A practical guide to successful living. Far Hills, NJ: New Horizon Press.AnxietyCraske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and worry workbook (2nd ed.). New York, NY: oxford University Press.Bourne, E.J. (2005). The anxiety and phobia workbook (4th ed.). Oakland, CA: New Harbinger Publications.Davidson, J., & Dreher, H. (2004). The anxiety book. New York, NY: Riverhead Books.Davis, M., Eschleman, E. R., Mcay, M., & Flemming, P. (2008). The relaxation and stress reduction workbook. Oakland, CA: New Harbinger Publications.Hollowell, E. (1997). Worry: Controlling it and using it wisely. New York, NY: Ballantine Books.White, J. (1999). Overcoming generalized anxiety – Client manual: A relaxation, cognitive restructuring, and exposure-based protocol for the treatment of GAD. Oakland, CA: New Harbinger Publications.Grief/Loss UnresolvedKuscher, H. (2004). When bad things happen to good people. New York, NY: Anchor Books.Weissman, M. M. (1995). Mastering depression through interpersonal psychotherapy: Monitoring Forms. (Treatments that Work). New York NY: Oxford University Press.Weissman M. M. (1995). Mastering depression through interpersonal psychotherapy: Patient workbook (Treatments that Work). New York, NY: Oxford University.Zonnebelt-Smeenge, S., & DeVries, R. (1998). Getting to the other side of grief: Overcoming the loss of a spouse. Grand Rapids, MI: Baker Books.Neuroimaging in psychiatry: Potentials and pitfallsCurrent Psychiatry. 2019 December;18(12):27-28,33-34By?Robyn Thom, MD??Helen M. Farrell, MDAuthor and Disclosure InformationPDFPDF?PDF?DOWNLOAD HYPERLINK "" HYPERLINK "" \t "_blank" HYPERLINK "" \t "_blank" HYPERLINK "" \t "_blank" HYPERLINK "mailto:?subject=Neuroimaging%20in%20psychiatry:%20Potentials%20and%20pitfalls&body=" \t "_blank" Advances in neuroimaging over the past 25 years have allowed for an increasingly sophisticated understanding of the structural and functional brain abnormalities associated with psychiatric disease.1?It has been postulated that a better understanding of aberrant brain circuitry in psychiatric illness will be critical for transforming the diagnosis and treatment of these illnesses.2?In fact, in 2008, the National Institute of Mental Health launched the Research Domain Criteria project to reformulate psychiatric diagnosis based on biologic underpinnings.3In the midst of these scientific advances and the increased availability of neuroimaging, some private clinics have begun to offer routine brain scans as part of a comprehensive psychiatric evaluation.4-7?These clinics suggest that single-photon emission computed tomography (SPECT) of the brain can provide objective, reliable psychiatric diagnoses. Unfortunately, using SPECT for psychiatric diagnosis lacks empirical support and carries risks, including exposing patients to radioisotopes and detracting from empirically validated treatments.8?Nonetheless, given the current diagnostic challenges in psychiatry, it is understandable that patients, parents, and clinicians alike have reported high receptivity to the use of neuroimaging for psychiatric diagnosis and treatment planning.9While neuroimaging is central to the search for improved understanding of the biologic foundations of mental illness, progress in identifying biomarkers has been disappointing. There are currently no neuroimaging biomarkers that can reliably distinguish patients from controls, and no empirical evidence supports the use of neuroimaging in diagnosing psychiatric conditions.10?The current standard of clinical care is to use neuroimaging to diagnose neurologic diseases that are masquerading as psychiatric disorders. However, given the rapid advances and availability of this technology, determining if and when neuroimaging is clinically indicated will likely soon become increasingly complex. Prior to the widespread availability of this technology, it is worth considering the potential advantages and pitfalls to the adoption of neuroimaging in psychiatry. In this article, we:outline arguments that support the use of neuroimaging in psychiatry, and some of the limitationsdiscuss special considerations for patients with first-episode psychosis (FEP) and forensic psychiatrysuggest guidelines for best-practice models based on the current evidence.Advantages of widespread use of neuroimaging in psychiatryCurrently, neuroimaging is used in psychiatry to rule out neurologic disorders such as seizures, tumors, or infectious illness that might be causing psychiatric symptoms. If neuroimaging were routinely used for this purpose, one theoretical advantage would be increased neurologic diagnostic accuracy. Furthermore, increased adoption of neuroimaging may eventually help broaden the phenotype of neurologic disorders. In other words, psychiatric symptoms may be more common in neurologic disorders than we currently recognize. A second advantage might be that early and definitive exclusion of a structural neurologic disorder may help patients and families more readily accept a psychiatric diagnosis and appropriate treatment.In the future, if biomarkers of psychiatric illness are discerned, using neuroimaging for diagnosis, assessment, and treatment planning may help increase objectivity and reduce the stigma associated with mental illness. Currently, psychiatric diagnoses are based on emotional and behavioral self-report and clinical observations. It is not uncommon for patients to receive different diagnoses and even conflicting recommendations from different clinicians. Tools that aid objective diagnosis will likely improve the reliability of the diagnosis and help in assessing treatment response. Also, concrete biomarkers that respond to treatment may help align psychiatric disorders with other medical illnesses, thereby decreasing stigma.Cautions against routine neuroimagingThere are several potential pitfalls to the routine use of neuroimaging in psychiatry. First, clinical psychiatry is centered on clinical acumen and the doctor–patient relationship. Many psychiatric clinicians are not accustomed to using lab measures or tests to support the diagnostic process or treatment planning. Psychiatrists may be resistant to technologies that threaten clinical acumen, the power of the therapeutic relationship, and the value of getting to know patients over time.11?Overreliance on neuroimaging for psychiatric diagnosis also carries the risk of becoming overly reductionistic. This approach may overemphasize the biologic aspects of mental illness, while excluding social and psychological factors that may be responsive to treatment.Second, the widespread use of neuroimaging is likely to result in many incidental findings. This is especially relevant because abnormality does not establish causality. Incidental findings may cause unnecessary anxiety for patients and families, particularly if there are minimal treatment options.Third, it remains unclear whether widespread neuroimaging in psychiatry will be cost-effective. Unless imaging results are tied to effective treatments, neuroimaging is unlikely to result in cost savings. Presently, patients who can afford out-of-pocket care might be able to access neuroimaging. If neuroimaging were shown to improve clinical outcomes but remains costly, this unequal distribution of resources would create an ethical quandary.Finally, neuroimaging is complex and almost certainly not as objective as one might hope. Interpreting images will require specialized knowledge and skills that are beyond those of currently certified general psychiatrists.12?Because there is a great deal of overlap in brain anomalies across psychiatric illnesses, it is unclear whether using neuroimaging for diagnostic purposes will eclipse a thorough clinical assessment. For example, the amygdala and insula show activation across a range of anxiety disorders. Abnormal amygdala activation has also been reported in depression, bipolar disorder, schizophrenia, and psychopathy.13In addition, psychiatric comorbidity is common. It is unclear how much neuroimaging will add diagnostically when a patient presents with multiple psychiatric disorders. Comorbidity of psychiatric and neurologic disorders also is common. A neurologic illness that is detectable by structural neuroimaging does not necessarily exclude the presence of a psychiatric disorder. This poses yet another challenge to developing reliable, valid neuroimaging techniques for clinical use.Areas of controversyFirst-episode psychosis.?Current practice guidelines for neuroimaging in patients with FEP are inconsistent. The Canadian Choosing Wisely Guidelines recommend against routinely ordering neuroimaging in first-episode psychoses in the absence of signs or symptoms that suggest intracranial pathology.14?Similarly, the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Schizophrenia recommends ordering neuroimaging in patients for whom the clinical picture is unclear or when examination reveals abnormal findings.15?In contrast, the Australian Clinical Guidelines for Early Psychosis recommend that all patients with FEP receive brain MRI.16?Freudenreich et al17?describe 2 philosophies regarding the initial medical workup of FEP: (1) a comprehensive medical workup requires extensive testing, and (2) in their natural histories, most illnesses eventually declare themselves.Despite this inconsistency, the overall evidence does not seem to support routine brain imaging for patients with FEP in the absence of neurologic or cognitive impairment. A systematic review of 16 studies assessing the clinical utility of structural neuroimaging in FEP found that there was “insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment.”18Forensic psychiatry.?Two academic disciplines—neuroethics and neurolaw—attempt to study how medications and neuroimaging could impact forensic psychiatry.19?And in this golden age of neuroscience, psychiatrists specializing in forensics may be increasingly asked to opine on brain scans. This requires specific thoughtfulness and attention because forensic psychiatrists must “distinguish neuroscience from neuro-nonsense.”20?These specialists will need to consider the Daubert standard, which resulted from the 1993 case?Daubert v Merrell Dow Pharmaceuticals, Inc.21?In this case, the US Supreme Court ruled that evidence must be “‘generally accepted’ as reliable in the relevant scientific community” to be admissible. According to the Daubert standard, “evidentiary reliability” is based on scientific validity.21How should we use neuroimaging?While neuroimaging is a quickly evolving research tool, empirical support for its clinical use remains limited. The hope?is that future neuroimaging research will yield biomarker profiles for mental illness, identification of risk factors, and predictors of vulnerability and treatment response, which will allow for more targeted treatments.1The current standard of clinical care for using neuroimaging in psychiatry is to diagnose neurologic diseases. Although there are no consensus guidelines for when to order imaging, it is reasonable to consider imaging when a patient has22:abrupt onset of symptomschange in level of consciousnessdeficits in neurologic or cognitive examinationa history of head trauma (with loss of consciousness), whole-brain radiation, neurologic comorbidities, or cancerlate onset of symptoms (age >50)atypical presentation of psychiatric illness.How to Make a Memory BoxCreating a Memory Box for Residents with DementiaFor seniors with Alzheimer’s, a memory box helps recall people and events from the past. These memories, thought to be lost, can stimulate the senior emotionally and prompt conversation with loved ones. Something as simple as the feel of an old baseball glove, the familiar texture of seashells collected on vacation or childhood photos are the types of items that hold precious memories. A Memory Box containing these meaningful reminders can be a source of pleasure and encouragement for a loved one as they make the journey into old age.Memory boxes are frequently used in order to promote engagement opportunities for people living with Alzheimer’s disease or a related dementia. Memory boxes can prompt conversation and provide mental and emotional stimulation. For a person living with a memory-loss condition, the items or objects in a memory box can help them reflect on the past and recall people and events. A three-year-old’s works of art, a newspaper clipping, or a family photo; memory boxes hold items that bring us back to a time or even a moment that we hold dear. When a senior who has Alzheimer’s opens a memory box, it can stir thoughts of happy moments in life and give that person something to talk about.Research shows that talking with people who have Alzheimer’s disease or other dementias about their lives can create positive emotional experiences, reduce stress and provide a better quality of life. Memory boxes can help produce these beneficial responses by connecting residents to what they love or help them feel comfortable and happy. All of our lives are filled with items that hold special personal memories. A memory box should contain a variety of items that hold a special significance for the person diagnosed with a memory-loss condition. The items can be utilized to engage the person or to comfort the person when they need to be calmed.Reasons to Create a Memory BoxMemory boxes can link seniors to what they love or what makes them feel good about themselves. They can even help hold an Alzheimer’s patient’s identity, with keepsakes emphasizing an overall theme, person, holiday, or an event that lifts the senior’s spirit.It will take time to find the keepsakes to store in the memory box, but it is worth the effort. Here are five reasons to create a memory box for a senior loved with Alzheimer’s:Recall fond memories of youth, personal interests, children or history in general.Inspire conversation with caregivers, children or grandchildren.Exercise touch and other senses that the senior will rely on more and more as Alzheimer’s progresses.Spur creativity. The senior may want to create another box about a different life event or memory.Give you more insight to your loved one. When you search for keepsakes, you may find special items you did not realize the senior still had.Creating a Memory BoxThe first step in creating a memory box is to locate a suitable container. A Memory Box can take many forms—a basket, a plastic bin, a drawer or a shoebox, and can be as decorative or as simple as you like, but it should be a strong, robust box that is easy to store. A box 12 inches by 9 inches (about the size of a shoebox) is ideal. It should be easy to access and lift, store a number of items of reasonable shapes and sizes, and fit on your loved one’s lap or a small table. If the memory box has compartments, make sure they suit the senior’s fingers and dexterity. This box is something to share and use, so choose a box that will handle some wear and tear, and make sure it has a lid that the senior can open easily. Perhaps grandchildren can decorate the box or help contribute to the collection.What to IncludeThe memory box can include anything that means something to the resident. The contents should reflect the resident’s interests or his or her favorite things or memories. Items stored in a memory box can be personal, like a baby’s toy, or seemingly ordinary, like a blank postcard. A memory box should reflect the senior’s interests or a moment in history that has meaning to that individual.Remember that experiences stored in our brains are not just visual, so try to include items with different textures, scents or sounds. Each item should relate to a memory that can be revisited time and time again. Diaries, letters, newspaper articles and the like may be invaluable reminders. Be aware that some items may open the door to unhappy memories, and you may want to be sensitive to avoid or carefully address discussing these items.What Else to Consider in Choosing KeepsakesSafety–Avoid items that are potentially dangerous, precious, heavy, or sharp.Uniqueness–if an item is rare or irreplaceable, leave it out.Dexterity–items should be easy to handle, not too heavy;Significance–focus on items linked to positive memories.Texture–texture itself can help stir memories – a piece of satin from a favorite dress, a furry stuffed animal, a metal pocket tape measure can all trigger sensory memories.Fragrance- Include items that can be touched and smelled. A lavender sachet might remind them of the one they had in their drawer years ago.Also, bear in mind that the senior may not recognize items right away or understand why they were included, so consider labeling the items—even those that are obvious. For example: Billy’s baseball, Mother’s necklace, gardening trowel, etc. The labels can be attached directly to the items or handwritten tags can be attached to each item. Stickers can fall off, so string tags might work better. You can also include a sheet of paper that lists all the items with a short sentence or phrase about each one.Memory Boxes make a wonderful holiday gift!?Check out this article?for more ideas for gifts for your loved one.Don’t put it off! Make a memory box as soon as possible, when their memory is still at its sharpest and they can participate and tell the stories behind the items!Keepsake ideas for the memory boxCopies of Family photos (Be sure to label photos with names and perhaps the year they were taken.)Favorite book(s)Baseball glove, baseball, hockey puck, baseball cards, etc.Different types of fabrics the resident finds appealing or comfortingDried flowers, flower petals, pinecones, acorns and/or leavesFavorite Perfume or lotionPotpourri sachetA bar of a favorite soapChildren or grandchildren’s artworkGardening gloves or tool (Nothing sharp Please!)A family heirloom (NOT an irreplaceable one!)Vacation souvenirsA trophy or medalSeashells or a dried starfishLetter(s) from a loved oneA favorite recipe, perhaps from a Thanksgiving or cherished holiday mealSheet music or an old record of favorite songMusical instrumentFavorite CDKeychainPostcardsBaby toy or stuffed animalNewspaper clippingsjewelry (without pins), perhaps a favorite necklace that they frequently woreold coinswedding trinketa stuffed animalhairbrusha favorite pair of shoesa favorite article of clothinga Christmas ornament, stocking, or Hanukkah candlesa thimble, sewing pattern, or other craft itemThe possibilities for what can be included in a memory box are virtually endless. Be creative and collect a variety of memory-stimulating items designed specifically for the person with Alzheimer’s disease or dementia. When the memory box is completed, have the person handle each item and encourage them to share the special memories associated with them.You can create multiple memory boxes for different themes. Maybe one could hold memories of the kids and another of a favorite hobby. All keepsakes do not have to fit into a single box.When you open the memory box with your senior loved one, ask the senior to share his or her memories. You may find that an item that was meant to stir a certain memory brings on another. Or, it could inspire a waterfall of thoughts and conversation, leaving you with new, lasting memories of your senior loved one.Sources: “5 Reasons to Make a Memory Box for Alzheimer’s Patients,” ; “Creating a Memory Box,”; 2014-02-06/memory-boxes-for-patients; QIO/wp-content/uploads/2016/03/508_Creating-a-Memory-Box.pdfTeam Development and Coaching*From The Leadership Playbook of Silicon Valley’s Bill Campbell Trillion Dollar CoachThis chapter is designed to help you apply leadership principles to your business and life. This was created for leaders and will help one create more powerful and effective teams. It will also allow one to take ownership of one’s life by discovering strengths and weaknesses. Take your time in answering each question, and refer to the questions whenever you want to take your business and life to the next level. You can also refer to the questions whenever you need to problem solve. It is the responsibility of the supervisor to develop and identify the duties and responsibilities of the Psychological and Psychiatric Technician and forward copies to the Regional Manager, HR Director, and Senior Management. Don’t forget to enjoy the process!How compassionate do you consider yourself to be? Have you ever helped someone in need without expecting anything in return?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you ever helped a coworker or another leader with an assignment?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Describe a time when you worked really hard and decided that the work was worth it? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Did it feel rewarding?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you ever felt like you weren’t tough enough and felt lie you were too compassionate?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you ever acted out of compassion at work?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you ever felt behind because you focused on the wrong thing? This focus has likely served you later even though you may have thought it was a waste of time initially. How has this experience prepared you for your new role and how has it given you an edge?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you ever taken initiative or a risk that has turned out to be worth it?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do people often ask you for advice or run ideas by you?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you make time for the people in your life? Do you have any particular way of treating people which makes them feel welcomed?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your team feel like there is a sense of community among its members?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Can you tell when your team is dealing with a conflict or disagreement?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How do you feel with intragroup conflict within your team? Building community and designing a way to make decisions and breaking up disagreements is one good way.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your team have a coach?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you ever feel threatened when someone gives you advice or suggests another way of doing things? How can you become more secure in yourself and more open to suggestions?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Prioritizing TeamsDo you put teams first or individuals first? Do people on your team put themselves ahead of the team or vice versa?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How will you focus on the dynamics of your team? This will help the team solve challenges.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you focus on winning?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What can the people on your team do to solve challenges?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How is the team usually chosen at your company?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you surround yourself with smart people who are perhaps brighter than you are?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you have grit? Are the people on your team able to persevere?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you surround yourself with people who get excited when someone succeeds?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you someone who shows up to do work? Are you surrounded by doers as well?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you hire individuals who are experienced or those who appear to have potential?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are your team members in a good relationship with each other? Is the team tightly knit?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you have people work in a group on projects?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are there a lot of women on your team or your company’s team?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you address the big issues facing your company, project or product or do you shy away from discussing the biggest problem?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Is there an issue that needs to be discussed which hasn’t’ been addressed in ages? This can be in business or your personal life.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Would you describe yourself as a positive person?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you demanding and passionate?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you place an emphasis on winning?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you tend to doubt yourself a lot? How about your team? How can you become more committed?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What causes are you committed to?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Community, Teamwork, and CoachingDo you sometimes feel alone or have a hard time finding people who are at your level?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you often feel confident? What are some of your insecurities and uncertainties? Be honest.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you feel like your appreciated at home and at your workplace? Do you make others feel appreciated?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your team feel like a community?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you have a coach?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How can the managers at your company be trained as coaches?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do the teams at your company have the resources they need to succeed? Do they have freedom to take initiative?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you and the leaders at your company have deadlines for making decisions____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you believe that your company makes great products that serve the market and people?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________MicrolearningMicrolearningFrom Wikipedia, the free encyclopediaMicrolearning?deals with relatively small learning units and short-term learning activities. The term is used in?e-learning?and related fields in the sense of?learning?processes in mediated environments. Microlearning is a holistic approach for skill based learning and education which deals with relatively small learning units. It involves short-term-focused strategies especially designed for skill based understanding/learning/education. Microlearning refers to micro-perspectives of learning, education, training and skill development. The approaches followed for assessment of microlearning are multidimensional & holistic in nature and need based in particular cases. An ideal instructional approach for many situations especially in higher education for skill development, trainability and employability of learners/students. The technique is capable enough to address challenges associated with slow learners. This learning technique is versatile not only for skill based education but also for sustainable socioeconomic development. Without taking care of micro-perspectives in the context of learning, education, training and skill development, a skill based education cannot be imparted effectively.In a wide sense, microlearning can be understood as a metaphor which refers to micro aspects of a variety of learning models, concepts and processes.No matter if learning refers to the process of building up and organizing?knowledge, to the change of?behaviour, of?attitudes, of?values, of mental abilities, of?cognitive?structures, of emotional reactions, of action patterns or of societal dimensions, in all cases we have the possibility to consider micro,?meso?and?macro?aspects of the various views on more or less persisting changes and sustainable alterations of performances.—?(Hug 2005, p. 4)Depending on frames and domains of reference, micro, meso and macro aspects vary. They are relational concepts. For example, in the context of language learning, one might think of micro aspects in terms of vocabularies, phrases, sentences, and distinguish them from situations and episodes (meso aspects) and socio-cultural specifics or complex semantics (macro aspects). In a more general discourse on learning, one might differentiate between the learning of individuals, group learning or learning of organizations and the learning of generations or societies.Furthermore, microlearning marks a transition from common models of learning towards micro perspectives on and the significance of micro dimensions in the process of learning. The microlearning approach is an emergent?paradigm, so there are no hard definitions or coherent uses of the term yet. However, the growing focus on microlearning activities can be seen by?web?users' activities on the subject, who?tag?their corresponding?weblog?postings and?social bookmarks?with the term "microlearning".As an?instructional technology, microlearning focuses on the design of microlearning activities through micro steps in digital media environments, which already is a daily reality for today's?knowledge workers. These activities can be incorporated into learner's daily routines and tasks. Unlike "traditional" e-learning approaches, microlearning often tends towards?push technology?through?push media, which reduces the?cognitive load?on the learners. Therefore, the selection of micro?learning objects?and also pace and timing of microlearning activities are of importance for didactical designs.Contents1Characterization2Dimensions3Subscription learning4Examples of activities5Applications (examples)6See also7References7.1General ReferencesCharacterization[edit]Microlearning can be characterized as follows:Microlearning processes often derive from interaction with?micro-content, which takes place either in designed (media) settings (e-learning) or in emergent micro-content structures like weblog postings or social bookmark managers on the?World Wide Web?[1]Microlearning can be an assumption about the time needed to solve a learning task, for example answering a question, memorizing an information item, or finding a needed resource?[2]?. Learning processes that have been called "microlearning" can cover a span from few seconds (e.g. in mobile learning) up to 15 minutes or more. There is some relation to the term?micro-teaching, which is an established practice in teacher education.Microlearning can also be understood as a?process?of subsequent, "short" learning activities, i.e. learning through interaction with micro-content objects in small timeframes. In this case, the design, selection, feedback and pacing of repeated or otherwise "chained" microlearning tasks comes into view.In a wider sense, microlearning is the way more and more people are actually doing informal learning and gaining knowledge in micro-content,?micro-media?or?multitasking?environments (microcosm), especially those that become increasingly based on?Web 2.0?and?wireless?technologies. In this wider sense, the borders between microlearning and the complementary concept of?micro-knowledge?are blurring.Dimensions[edit]The following dimensions can be used to describe or design microlearning activities[3]:Time:?relatively short effort, operating expense, degree of time consumption, measurable time,?subjective time, etc.Content:?small or very small units, narrow topics, rather simple issues, etc.Curriculum:?small part of curricular setting, parts of modules, elements of informal learning, etc.Form:?fragments, facets, episodes, "knowledge nuggets", skill elements, etc.Process:?separate, concomitant or actual, situated or integrated activities, iterative method,?attention management, awareness (getting into or being in a process), etc.Mediality:?print media, electronic media, mono-media vs. multi-media, (inter-)mediated forms, etc.Learning type:?repetitive, activist, reflective, pragmatist,?conceptualist, constructivist,?connectivist, behaviorist; also:?action learning, classroom learning, corporate learning, etc.Subscription learning[edit]"Subscription learning, as its name implies, provides an intermittent stream of learning-related interactions to those who are subscribed. These learning-related interactions—called "nuggets"—can involve a great variety of learning-related events, including content presentation, diagnostics, scenario-based questions, job aids, reflection questions, assignments, discussions, etc.?Nuggets?are short, usually presented in less than five to ten minutes. Nuggets are intentionally scheduled over time to support learning, often utilizing research-based findings related to the spacing effect. Learners subscribe (or are subscribed) to one or more series of learning nuggets, called "threads". Learning threads can be predesigned, selecting nuggets based on anticipated learner needs or they can be dynamically created based on learner performance."?[4]Subscription learning characteristics:Learners subscribe or are subscribed to a series ("threads") of short informational interactions ("nuggets").Interactions usually last less than five or ten minutes.Learners usually receive these nuggets through some form of push technology.Subscription-learning threads are usually—and preferably—designed using the scientific find known as the spacing effect.?[4]Examples of activities[edit]reading a paragraph of?text,?e-mail?or?smslistening to an informational (short)?podcastwatching a short video clipviewing a?flashcardmemorizing a word, vocabulary, definition or formulasorting a set of (micro-content) items by chronological orderselecting an answer to a questionanswering questions in quizzesplayful learning with micro-gamescomposing a?haiku?or a short poemwriting or drawing a reflection on just-viewed contentrating confidence in an answer to a questionApplications (examples)[edit]Screensavers which prompt the user to solve small series of simple tasks after a certain amount of inactivityQuizzes with?multiple choice?options on?cell phones?by use of?sms?or mobile applications (java?midlets,?symbian)Word of the day as daily?RSS-feed or?e-mailFlashcard-software for memorizing content through?spaced repetitionShort videos (2-10 minutes) either presented stand alone or in a seriesSee also[edit]MicroformatsMicrolectureReferences[edit]^?Mosel, Stephan (2005):?Self Directed Learning With Personal Publishing and Microcontent. Constructivist Approach and Insights for Institutional Implementations.?Paper presented at the Microlearning 2005 conference, June 23–24, 2005, Innsbruck, Austria.^?Masie, Elliott (2006):?Nano-Learning: Miniaturization of Design. Media Tec Publishing Newsletter^?Hug, Theo (2005):?Micro Learning and Narration. Exploring possibilities of utilization of narrations and storytelling for the designing of "micro units" and didactical microlearning arrangements. Paper presented at the fourth Media in Transition conference, May 6–8, 2005, MIT, Cambridge (MA), USA.^?Jump up to:a?b?Thalheimer, Will (2013).?Subscription Learning (website).General References[edit]Gassler, Gerhard; Hug, Theo & Glahn, Christian (2004): Integrated Micro Learning – An outline of the basic method and first results. In: Auer, Michael E. & Auer, Ursula (eds.): International Conference on Interactive Computer Aided Learning, ICL 2004, Sept. 29 – Oct. 1, 2004, Villach, Austria (CD-ROM).Gstrein, Silvia & Hug, Theo (2005): Integrated Micro Learning during Access Delays. A new approach to second language learning. In: Zaphiris, Panayiotis (ed.): User-centered computer assisted language learning. Hershey: Idea Group Publishing, pp. 152–175.Hagleitner, Wolfgang; Drexler, Arthur; Hug, Theo (2006). Evaluation of a prototypic version of Knowledge Pulse in the context of a management course. Paper presented at the Multimedia Applications in Education Conference, 2006, September 4–6, FH Joanneum, Graz, Austria.Hug, Theo; Lindner, Martin; Bruck, Peter A. (eds.) (2006):?Microlearning: Emerging Concepts, Practices and Technologies after e-Learning. Proceedings of Microlearning 2005. Innsbruck: Innsbruck University Press, 2006.Weber, Charles M. (2003):?Rapid Learning in High Velocity Environments. Ph.D. thesis, Massachusetts Institute of Technology (M.I.T.Additional Education of Nursing Home Staff and Other ProfessionalsIndex of Senior Minutes from Website Oversight Blamed for Poor Care at California Nursing Homes Going UncheckedPrevalence of Prescription Medications With Depression as a Potential Adverse Effect Among Adults in the United States.How much time have you spent thinking about the role of reassurance in Alzheimer’s care?Action Alert! Reimbursement Rate Cuts for dual eligible Medicaid/MedicareUse of Antidepressants in Nursing Homes and the Need for Depression Screening ToolsDementia: FAQ SessionOff-Label Prescriptions: Liability and Legality IssuesFamily Adjustment to Admission of Nursing Home Protocols in Resource ManualSee Mid-Level Guidelines in Resource ManualADDENDUM PART IIIFor more in-depth information on duties and responsibilities review the information on huddles and behavioral rounds in the resource manual.SPECIALTY MEDICINEThe areas of medicine that are utilized by patients who need additional “specialized” evaluation or treatment, beyond the scope of what primary care can provide. Specialists may have a longer training program or a more general residency (such as internal medicine or general surgery) followed by “fellowship training” in their chosen specialty.Many specialists also may act as consultants. A consultant is someone who evaluates a patient and provides recommendations for a treatment plan to the patient’s primary health care provider (like an emergency medicine physician or a hospitalist). A specialists (or consultant) only documents on active problems within his or her area of expertise. For example: a general surgeon might only comment on the surgical procedure that he or she performed, and any perioperative complications. Things like hypertension or pulmonary disease would be managed by specialists on the treatment team, perhaps cardiology and pulmonology, respectively. Included in the area of specialty medicine are the following specialties. Organized alphabetically. This is not a complete list of all specialties of which there are many.Anesthesiologist: Care of the patient undergoing surgery and requiring anesthesia. May also deal in pain management for patients who have chronic pain problems.Cardiologist: Manages diseases of the cardiovascular system. Can also subspecialize into other branches of cardiology, such as interventional cardiology, to perform procedures using a catheter, or electrophysiology, to treat and manage diseases of the heart’s electrical system, among others.Dermatologist: Deals with issues related to the skin. May do in-office procedures like biopsies and excisions.Gastroenterologist: Manages and treats diseases of the gastrointestinal tract. Can perform procedures in an office setting and/or in the hospital, like colonoscopies, upper endoscopies and biopsies, to name a few.General surgeon: A surgeon who has not subspecialized into other types of surgery. The types of surgeries that are performed depend on the surgeon’s level of training. These may include abdominal surgeries, minor surgeries, etc.Hematologist/Oncologist: Treats cancer patients and diseases of the blood.Hospitalist: A relatively new specialty which takes care of patients in the hospital only and then returns them to their primary care provider or other specialist for outpatient care. A hospitalist will only document on any problem that requires close monitoring or intervention while the patient is hospitalized. They will not generally address stable or old problems. This is typically the next point of contact for patients who are admitted to the hospital form the emergency room.Nephrologist: Specializes in diseases of the kidneys, including caring for dialysis patients.Neurologist: Provides medical care of neurological problems.Neurosurgeon: Provide surgical care of neurological problems.Otolaryngologist (ENT): Provide office and surgical care relating the the ears, nose, and throat.Ophthalmologist (eyes): Provides office and surgical care of eye problems.Physical Medicine and Rehabilitation (PM&R); Rehabilitates the injured, stroke victims and others. Plastic surgeon: Performs reconstructive and/or cosmetic procedures.Proctologist: Takes care of diseases in the rectal area.Psychiatrist: Cares for patients with mental illness.Pulmonologist: Specializes in diseases of the lung. Pulmonologists may also practice critical care medicine.Radiologist: Reads and interprets various types of imaging studies. May also subspecialize into interventional radiology and perform imaging guided catheterization procedures.Rheumatologist: Monitors and treats the rheumatologic autoimmune diseases (those dealing with muscles and joints, primarily). Autoimmune disease tends to have a multi-system overlap, so rheumatologists often consult with other specialists to manage autoimmune disease (like dermatology and gastroenterology, for example).Urologist: Manages diseases of the urinary system, other than the kidneys (urinary bladder, ureter and ureters). This is a surgical subspecialty.Vascular (thoracic) surgeon: Performs invasive surgeries of the heart, lungs, and blood vessels.The consulting pharmacist reviews medications and guidelines of CMS and other administrative agencies and keeps medical staff informed of those regulations. A pharmacist may advise discontinuing a certain medication but the provider may ignore the recommendation of the pharmacist if he documents that this is not in the best interest of the patient.“ANSWER KEY” EXAMPLE 1: The patient is a 53 year old male who presents with chest pain.HISTORY OF THE PRESENT ILLNESSThe patient is a 53 year old male with chest pain. The patient reports that about an hour ago he was shoveling snow and began to have an acute onset of sharp sternal chest pain radiating into his left jaw and shoulder. Pain is exertionally related, but there is not a pleuritic component that he can identify. He also became diaphoretic and short of breath, but denies nausea or vomiting. No fevers, although he has a nonproductive cough which he attributes to his smoking history that sounds to be stable and chronic. The patient was given nitroglycerin en route by paramedics and states that his pain improved from a 10/10 to a 2/10. Otherwise, he denies visual symptoms, a sore throat, abdominal pain, dysuria, leg pain or swelling, headaches, rashes, or any other symptoms.Significant medical history include diabetes, hypertension, and hyperlipidemia, all currently unmedicated due to patient’ medication noncompliance. He is not anti-coagulated. No personal history of Cad or MI. He also has a strong family history of cardiac disease, with reported MI in both his father and paternal grandfather.DESCRIPTORS (BILLABLE ELEMENTS)Duration: One hourOnset: Acute/Timing: Improving after nitroglycerinLocation: Sternal/Radiation: Left jaw and shoulderCharacter/Quality: SharpIntensity: 10/10 before nitroglycerin, and 2/10 after nitroglycerinAssociated Symptoms: Diaphoresis, shortness of breath, nonproductive cough (Chronic and stable)Context: Pain began while he was shoveling snowModifying factors: Pain exertionally worsened; no pleuritic component/ Tx before arrival: Nitroglycerin with significant reliefREVIEW OF SYMPTOMSConstitutional: No fever.Eye: No visual changes.HENT: No sore throat.Resp: Positive dyspnea and cough.Cardio: Positive chest pain.GI: No abdominal pain, nausea, vomitingMusculoskeletal/Extremities: No leg pain or swelling.Neuro: No headaches.Skin: No rash. Positive diaphoresis.PHYSICAL EXAMConstitutional: Well developed and obese male.HENT: Normocephalic, Atraumatic. Dry mucous membranes.Neck: Jugular venous distention.Cardiovascular: Tachycardic and occasional irregular. 3/6 systolic ejection murmur. No rubs or gallops.Thorax & Lungs: Normal breath sounds but diminished throughout. No chest wall tenderness.Abdomen: Soft and non tender.Skin: Diaphoretic.Musculoskeletal/Extremities: 1+ pitting edema bilaterally. No calf tenderness. KEY POINTS EXAMPLE 1:This patient has many classic signs and symptoms that m ay indicate cardiac chest pain. His pain is sternal, radiating to the left arm and the jaw, he is short of breath and diaphoretic, and his pain was relieved with nitroglycerin. He has all of the risk factors, including high blood pressure, high cholesterol, diabetes, tobacco abuse, and a strong family history of cardiac disease.The importance of “pertinent” negatives was demonstrated in this example. The patient described his pain as sharp, but denied a pleuritic component (pain with deep inspiration). This makes the odds even less likely that his symptoms are due to something like a pulmonary embolus or pneumonia, and more likely to be of cardiac etiology.Sometimes, patients will give nonverbal cues describing their current condition. In this example, the patient indicated that his chest pain was sternal by pointing. In a real scribing situation, you will likely be actively working n a computer as the provider and patient ware interacting, but you must be mindful of these nonverbal cues as well. Patient’s will describe the things they feel in the best manner they know how. It is your job, as the scribe, to translate the layman’s terms into medical jargon. The patient said that he was shoveling snow when the chest pain began, but what you should take away from this is that the chest pain is exertional. He also said that he soaked his shirt with his sweat; thus, you should document “diaphoresis”.You will encounter irrelevant information often. Part of the “art” of scribing is knowing how to filter this out and exclude it from your history. The comment made about his uncle’s diabetes isn’t relevant to the patient’s current complaints and, thus, was excluded from the history. In the physical exam, “jugular venous distension” was included under the “neck” exam because it is conventionally found here. If you included this finding under “cardiovascular,” you’re not wrong, but it would be better placed in the “neck” exam. This does not change anything from a billing perspective because the “neck” exam, “back” exam, and “musculoskeletal/extremities’” count as one system together for billing. DIALOGUE 2: The patient is a 26 year old female who presents with shortness of breath. Provider: Tellme about the shortness of breath you’ve been having.Patient: I’ve had this respiratory infection for a few days now. A sore throat, a runny nose, congestion, a cough. Yesterday I was watching TV and all of a sudden started having shortness of breath.Provider: Do you have any fevers? Do you cough anything up?Patient: I’ve had a low grade fever a few times with chills. I’ve been having a dry cough too.Provider: Do you have an y chest pain or lightheadedness/dizziness?Patient: I get sharp pains on the right side of my chest when I Breathe, but it doesn’t happen all the time. Oh, and I have some chest pain after coughing. I don’t have any of the other things though.Provider: Have you travelled anywhere recently? Any recent surgeries or illnesses?Patient: Two weeks ago I went ot Jamaica for vacation. I just got back about a week ago.Provider: Do you have pain in your calves or leg swelling?Patient: Nope.Provider: Do you have a history of cancer or lupus or blood clots in your lungs or legs?Patient: I’ve never been diagnosed with anything but asthma as a kid, but I havent’ had problems with the asthma in adulthood.Provider: Does anyone in your family have a history of blood clots in the lungs or legs?Patient: Not that I know of.Provider: Are you on birth control or other hormones?Patient: I take daily birth control pills.Provider: Do you smoke?Patient; I’ve never smoked but my mom always smoked in our house when I was growing up.Provider: Just a few more routine question. Do you have any visual changes, nausea, vomiting, diarrhea, burning with urination or blood in your urine, headaches, rashes, or any other symptoms?Patient; None of those.PHYSICAL EXAM FINDINGS EXAMPLE 2:This is a well developed and well nourished female. Moist mucous membranes. Nose is congested and there is scant clear rhinorrhea. Posterior oropharynx is somewhat erythematous but no tonsillar swelling or exudates. TMs clear bilaterally. No anterior cervical lymphadenopathy. Borderline tachycardia but with a regular rhythm. No murmurs, rubs, or gallops., A few end expiratory wheezes but but breath sounds are otherwise normal. No chest wall tenderness. Abdomen is soft and non-tender. No calf tenderness. Negative Homan’s sign. Strong dorsalis pedis and posterior tibial pulses and normal capillary refill. No focal defects. “ANSWER KEY” EXAMPLE 2: The patient is a 26 year old female who presents with shortness of breath.HISTORY OF THE PRESENT ILLNESSThe patient is a 26 year old female with shortness of breath. The patient reports that for the past few days she has had a persistent sore throat, rhinorrhea, congestion, and a nonproductive cough. Yesterday she began having an acute onset of dyspnea while watching TV. There is a pleuritic component and she also has some post tussive chest pain. She has had intermittent low grade fevers and chills. No lightheadedness or dizziness. No leg pain or swelling. Two weeks ago, the patient flew to Jamaica for vacation. She is on oral contraceptives. Otherwise, she denies visual changes, nausea, vomiting, diarrhea, dysuria or hematuria, headaches, rashes, or any other symptoms. Significant medical history includes childhood asthma, now apparently resolved in adulthood. No history of hyper coagulability, including cancer, lupus, or DVT/PE. No family history of hypercoagulability including DVT or PE. The patient is a nonsmoker but she had passive smoke exposure in childhood. DESCRIPTORS (BILLABLE ELEMENTS)Duration: A few daysOnset: Acute/Timing; Persistent and worsening yesterdayLocation: Right chestCharacter/Quality; SharpAssociated Symptoms: Shore throat, rhinorrhea, congestion, nonproductive cough, fevers, chills, pleuritic and post tussive chest painContext: Symptoms began while she was watching TVModifying factors: Pleuritic and post tussive chest pain REVIEW OF SYSTEMSConstitutional: Positive fever and chills.Eye: No visual changes.HENT: Positive sore throat, rhinorrhea, congestion.Resp: Positive nonproductive cough, dyspnea, pleuritic chest pain.Cardio: No leg pain or swelling.GI; No nausea, vomiting, or diarrhea.GU: No dysuria or hematuria.Musculoskeletal/Extremities: Positive post tussive chest pain.Neuro: no headaches.Skin: No rash.PHYSICAL EXAMConstitutional: Well developed and well nourished femaleHENT: Moist mucous membranes. Nose is congested with scant clear rhinorrhea. Posterior oropharynx somewhat erythematous, but no tonsillar swelling or exudates. TMs clear bilaterally.Lymphatic: No anterior cervical lymphadenopathy.Cardiovascular: Borderline tachycardia. Regular rhythm. No murmurs, gallops, or runbs.Thorax & Lungs: Few end expiratory wheezes, but otherwise normal breath sounds. No chest wall tenderness.Abdomen: Soft and non tender.Skin: Normal capillary refill to the lower extremities.Musculoskeletal/Extremities: No calf tenderness. Negative Homan’s sign. Strong DP/PT pulses.Neuro; No focal deficits. KEY POINTS EXAMPLE 2:This patient has many classic signs and symptoms that may indicate pulmonary embolus. She had a sudden onset of shortness of breath with pleuritic chest pain (pain that worsens with inspiration). She has many risk factors, including a recent flight to Jamaica and back daily oral contraceptive use. Additionally, although the patient doesn’t smoke, she has had long term exposure and this still constitutes a risk factor.Although there are many components of this encounter that may indicate pulmonary embolism, pertinent negatives are also important in this example. She denied leg pain or swelling or a personal or family history of hypercoagulability (cancer, lupus, DVT or PE). All of this information is assessed together with the pertinent positives when calculating a patient’s risk for disease.The patient made a comment about having childhood asthma, but being asymptomatic in adulthood. Although you are supposed to filter the relevant information from the irrelevant, since the patient is having shortness of breath, the patient’s remote history of asthma may be relevant so it was included. In review of systems, “no leg pain or swelling’ was included under “cardiovascular” in order to maximize the number of systems for billing (can also be found in “musculoskeletal/extremities”). Remember, you should try and achieve the maximum number of systems (the recommendation is 10 for review of systems) in order to bill for the highest complexity visit your provider deems appropriate.In physical exam, “normal capillary refill to lower extremities” was included under the “skin” exam in order to maximize the number of systems for billing (also found in “musculoskeletal/extremities”)> Try to achieve the maximum number of systems (the recommendation is 8) within the for physical exam in order to bill for the highest complexity visit.PHYSICAL EXAMConstitutional: Well developed and well nourished femaleHENT: Moist mucous membranes. Nose is congested with scant clear rhinorrhea. Posterior oropharynx somewhat erythematous, but no tonsillar swelling or exudates. TMs clear bilaterally.Lymphatic: No anterior cervical lymphadenopathy.Cardiovascular: Borderline tachycardia. Regular rhythm. No murmurs, gallops, or runbs.Thorax & Lungs: Few end expiratory wheezes, but otherwise normal breath sounds. No chest wall tenderness.Abdomen: Soft and non tender.Skin: Normal capillary refill to the lower extremities.Musculoskeletal/Extremities: No calf tenderness. Negative Homan’s sign. Strong DP/PT pulses.Neuro; No focal deficits. KEY POINTS EXAMPLE 2:This patient has many classic signs and symptoms that may indicate pulmonary embolus. She had a sudden onset of shortness of breath with pleuritic chest pain (pain that worsens with inspiration). She has many risk factors, including a recent flight to Jamaica and back daily oral contraceptive use. Additionally, although the patient doesn’t smoke, she has had long term exposure and this still constitutes a risk factor.Although there are many components of this encounter that may indicate pulmonary embolism, pertinent negatives are also important in this example. She denied leg pain or swelling or a personal or family history of hypercoagulability (cancer, lupus, DVT or PE). All of this information is assessed together with the pertinent positives when calculating a patient’s risk for disease.12. EKG NOTESEKG or ECG (electrocardiogram): This is a tracing of the electrical activity of the heart that is recorded on grid paper. This electrical activity is expressed as a linear tracing of the strength (amplitude) of that electrical activity, which appears as waves or a waveform pattern on the graph paper. The duration (x-axis), represents time in second (s), or milliseconds (ms). The amplitude (y-axis) represents voltage in millivolts (mV). The configuration, or morphology, of the wave is also examined. The EKG tracing is created by the placement of 10 different leads, or electrodes, in specific locations on the patient’s chest (also known as the precordium) and limbs. Each of these leads, or in some cases weighted averages of several leads measures the strength and direction of the electrical activity of the heart and translates that information into the EKG waveforms that are seen on the graph. These leads are represented by a combination of numbers and letters, and each has its own unique name. The precordial leads are denoted as V1 through V6 and the limb leads are denoted as I, II, II, aVR, aVL & aVF. Each of the important points on an individual EKG waveform is named to help easily identify which part of the cardiac cycloe it represents. The rhythm strip is an extended version of lead II at the bottom of the EKG. It is impo0rtant that you become familiar with the different combinations of numbers and letters and the nomenclature used to describe an EKG.Using the EKG template: For ease of documentation, a template may be created to allow for faster and more accurate charting. An example of such a template is seen above in the sample note. This template documents a completely normal EKG. TO use the template properly, you must:Insert the provider’s dictated interpretation into the proper locations within the template.Remove contradicting statement. Notice that the EKG template documents a completely normal EKG. IF “right bundle branch block” is noted for “conduction, “you must remember to remove “normal.” If not removed, this will become a contradicting statement. EKG findings: The following is a partial list of EKG findings that can be included in an interpretation, along with a concise description of each element and under which heading of the template the element belongs. It is not necessary to memorize specific details about EKGs.Time: Time EKG was taken and interpreted.Rhythm: The regularity with which the heart is beating.Normal sinus - sinus rhythm with a “normal” hear rate (between 60 and 100bpm)Bradycardia – slow heart rate (<60 bpm)Sinus tachycardia – sinus rhythm with a rapid heart rate (>100 bpm)Atrial tachycardia – tachycardia originating in the atriumAtrial fibrillation – irregularly irregular arrhythmia with or with out rapid ventricular response (RVR)Atrial flutter – supraventricular tachycardia with an elevated atrial rateAtrial paced (AAI) – a pacemaker is in place and has initiated atrial pacing of the heartVentricular paced (VVI) – a pacemaker is in place and has initiated ventricular pacing of the heartAtrial/ventricular dual paced – pacemaker senses cardiac activity and paces the atrium and the ventriclesRate: How fast the heart is beating on average per minute (beats per minute or bpm).Axis: The direction of electrical flow in the heart. In different cardiac conditions, the flow may be altered and can help the clinician to interpret what is happening in the heart. The axis can be imagined as the hands on a clock with a range from the 11 o’clock to 55 o’clock position. Normal Axis – electric conduction runs from about 2 o’clock to 6 o’clock.Left axis deviation – electric flow moves in a clockwise direction relative to normalRight axis deviation – electric flow moves in a counterclockwise direction relative to normalExtreme right axis deviation – electric flow through the heart is diverted in an extremely abnormal mannerEctopy: Premature beats from the atrium or the ventricle or elsewhere within the heart.Premature atrial complex (PAC) – premature beat(s) from the atriumPremature ventricular complex (PVC)- premature beat(s) from the ventriclePremature junctional complex (PJC) – premature beat(s) originating at the AV junctionConduction: This refers to the way in which electricity is conducted through the heart. Recall from above that the EKG traces the electrical activity of the heart. Numerous conditions may alter or disrupt this flow of electricity and can occur at various points along the path. One area with frequent conduction problems is the PR interval, which is the time from the start of the P wave to the beginning of the QRS complex. The P wave represents atrial depolarization, and the start of the QRS complex represents the beginning of ventricular depolarization. This measures the health and functionality of the AV node. Another area where conduction problems frequently occur is the QT interval, which is the time from the start of the Q wave to the end of the T wave. This represents the beginning of ventricular depolarization to the end of ventricular repolarization. Left bundle branch block (LBBB) – electricity is blocked from the left bundle branch in the septum of the heart and activation of the left ventricle is delayedRight bundle branch block (RBBB) – electricity is blocked from the right bundle branch in the septum of the heart and activation of the right ventricle is delayedNonspecific intraventricular conduction delay (IVCD) – prolonged QRS interval and a supraventricular rhythmAV block: 1st degree – slowed conduction through the AV node (PR interval >200 ms)AV block: 2nd degree – various subtypes involving intermittent non conduction through the AV nocxeAV block: 3rd degree – non conduction through the AV nodeLeft anterior fascicular block (LAFB) or left anterior hemiblock (LAHB) – electricity is blocked in this branch of the left ventricular conduction systemLeft posterior block (LPFB) or left posterior hemiblock (LPHB) – electricity is blocked in this brank of the left ventricular conduction systemProlonged QT interval (>400 ms) – calculated with a formula and recorded on the EKGP waves: The P wave is the first positive ewave preceding the QRS complex, representing atrial depolarization. Atrial repolarization cannot usually be seen, as it is hidden in the QRS complex.Left atrial enlargement (LAE)Right atrial enlargement (RAE)P wave morphology – Describes the shape and appearance of the P Waves. They can be inverted, peaked, or ectopicQRS complex: Multiple waveforms that represent ventricular depolarization. It include the Q wave (if present), one or more R waves (R and R’ (prime), respectively), and the S wave. This is the electrical signature of the heartbeat.QRS width (normal is 70-100 ms) – used to determine the origin of each QRS complexBroad waveform (>100 ms ) – QRS originates above the ventricles Narrow waveform )<70 ms) – QRS originates in the ventricles or elsewhereQRS voltage – comments on the height of each QRSLow voltage _ QRS complexes are shorter than normalHigh voltage – QRS complexes are taller than normalElectrical alternans - alternating between low and high voltagesQRS morphology – comments on the shape of QRS complexes for diagnostic purposesST segment: This represents the period from the end of ventricular depolarization to the beginning of ventricular repolarization. Abnormalities, including segment elevation or depression, may be indicative of acute cardiac ischemia or infarction , or may indicate electrolyte issues. T wave: The T wave is the first positive wave after the QRS complex that represents ventricular repolarization. Abnormalities can indicate evidence of acute cardiac ischemia or infarction, or may indicate electrolyte issues. Hyperacute T waves – broad /uneven T waves that may precede ST changes in acute MIInverted T waves – negative wave that is seen in a variety of conditionsBiphasic T waves – T wave splits and one wave deflects positively and the other negativelyFlattened T waves – T waves have lost amplitude and appear flattenedPeaked T waves – tall and peaked T waves that may indicate hyperkalemiaQ waves: The Q wave is the first part of the QRS complex. There can be Q waves that are considered normal, and you can expect to see these in certain leads. Other Q waves that are larger in amplitude and found in unexpected leads can indicate an acute MI, or can signify that an MI took place at some point in the past. S1Q3T3 – can indicate pulmonary embolism (deep S wave in lead I, pathologic Q wave in lead III, and inverted T wave in lead III)Poor R wave progression poor transition – usually seen with Q waves and may be due to lead placement problems or prior myocardial infarctionPresence/absence of abnormal Q waves and their location – tells the clinician if there has been a prior myocardial infarction and what blood vessel may have been involvedFinal Impression: The overall interpretation of the EKG. This could include phrases similar to “changes consistent with…” This could also include a summary of all EKG findings and comments about whether they are new or old and present on prior EKGs. Comparison: Any changes from a prior EKG may shed light on what is happening acutely (new onset). Be sure to document what has changed in the new EKG compared with any prior EKGs, and note their dates. There could also be no comparison, which should also be recorded if this is the case. Hematology: Examines type and quantity of blood cells and blood viscosity.CBC (complete blood count) w/differential – Measures the quantity and size of RBCs, quantity and type of WBCs, an quantity of platelets.PT/NR (prothrombin tie/international normalized ratio) – Measures various reaction to certain coagulation factors. Generally speaking, it refers to how “thin” the blood is. Generally doen for patients taking the blood thinner Coumadin (warfarin) or those with certain bleeding disorders.Blood bank: Determines blood type and qualities for transfusion.Type and screen – Determines blood type (ABO and Rh) and tests for any additional antibodies that may cause a transfusion reaction.Type and cross match – Determines blood type (ABO and Rh) and tests the compatibility of the donor blood with the recipient blood prior to infusion.Chemistries: Examines electrolyte, hormone, and enzyme levels.CMP (comprehensive metabolic panel) – Measures electrolytes, serum glucose, renal function, and hepatic function.BMP (basic metabolic panel) – Measures electrolytes, serum glucose and renal function.LFT (liver function test)/hepatic panel – Measures hepatic function.Lipase – Measures the quantity of the pancreatic enzyme lipase.hCG (human chorionic gonadotropin/”beta quant” – Measures the amount of a hormone that is excreted by an embryo after implantation in the uterus. Used to monitor pregnancyPOC (point of care) glucose – Blood strip test measuring serum glucose (sugar).THS (thyroid stimulating hormone) – Measures the quantity of serum thyroid hormone secreted by the pituitary gland. Used to screen for and monitor thyroid disease.T4 (free T4) – Measures the quantity of serum T4 (thyroxine) secreted by the thyroid gland.Magnesium level – Measures serum magnesium.Phosphorous level – Measure serum phosphorous.Sedimentation rate (sed rate) – Measure of inflammation in the body.Zinc level – Measures serum zinc.Pro-BNP (B-type natriuretic peptide) – Hormone released by the ventricles of the heart in response to increased vascular resistance. Used to screen for/monitor heart failure.Troponin – Cardiac enzyme released in response to cardiac muscle cell damage.D-dimer – Protein that is released during the process of blood clot degradation. Used to screen for thrombosis (blood clots).Blood gases: Measures the pressures of various gases in the blood.VBG (venous blood gas) – Measures the partial pressure of gases within venous blood.ABG (arterial blood gas) – Measures the partial pressure of gases within arterial blood.Urine: Examines the quality and content of urine.Urinalysis – Assesses the appearance of urine and measures the amount of protein, bacteria, and other molecules in the urine, as well as any cells present.POC (point of care) pregnancy – Dipstick urine pregnancy test.Microbiology: Examination of various pathogens within bodily fluids.Blood culture – Sample of blood that is allowed to “culture” (grow microbes) in order to identify any bacteria present.Urine culture –Sample of urine that is allowed to “culture” (grow microbes) in order to identify what bacteria are present.Influenza screen – Screen for different variants of the influenza virus.STD (sexually transmitted disease) screen – Screen for the most prevalent sexual transmitted infections (STIs).Strep screen – Screen for the presence/absence of streptococcus bacteria.Would culture – Sample from a wound that is allowed to “culture” (grow microbes) in order to identify what bacteria are present.Toxicology: Examination of various body fluids to identify any toxins.Serum toxicology screen – Screen for toxic substances in the blood.Urine toxicology screen – Screen for toxic substances in the urine.Serum ethanol level – Blood alcohol level.Digoxin level – Screen for serum digoxin toxicity (medication level).Other various blood levels – Medications such as lithium, Dilantin, tegretol and many others.Imaging: Any type of test used to better visualize an interior structure of the body. Can incude readiographic imaging (x-rays), CT scans, MRI, PET scans, ultrasound imaging, or nuclear medicine studies. In addition to specifying the region of the body to be imaged, all imaging of a paired body part must specify laterality (right or left or both).Of special interest in imaging, there are other considerations that a provider will likely have in mind prior to placing their imaging orders. The first is costliness. Some forms of imaging can be very expensive and/or not covered by certain insurance companies. Patients of a lower socioeconomic status may not be able to afford some modes of testing and, thus, may not agree to have them done. However, in the emergency room , urgency trumps costliness. The second consideration is radiation exposure. Many providers monitor the radiation a patient receives, typically from x-rays or CT scans. For perspective: one CT scan emits the same amount of radiation as approximately 250 chest x-rays! Increased radiation exposure has been positively correlated with an increase in the probability of developing cancer or fertility problems. Risk/cost versus benefit analysis is a term you may hear, which refers to an assessment of the potential value of information obtained by scans versus the possible long term effects of radiation exposure.The third consideration is possible time constraints. Especially in the emergency room, where even seconds to minutes can make a difference in a patient’s health outcome during the course of treatment, the type of imaging ordered must be correlated with the acuity of the situation. For example, MRIs are rarely ordered in the ED. Although there is no radiation exposure associated with this type of imaging, they are often not immediately available and they take notably longer to perform than CT scans, which are much quicker, but result in radiation exposure. Radiographs: X-rays capture an image of a body part, or region of the body, by using of an x-ray detector. Different body structures absorb x-rays differently than one another, which can be used to create an image.“Views”: Not only must you specify body part and laterality, when ordering imaging but also the view. Common examples include AP (anterior-posterior), PA (posterior – anterior), lateral, 3-view, 4-view, and puterized tomography (CT) scans: A series of radiographic (x-ray) images are spliced together to create a 3-D reconstruction of a region of the body.Contrast dye that is opaque on x-ray imaging is sometimes given prior to performing a scan. The contrast dye can be used to provide a better view of all internal structures within the part of the body that is being scanned. In other cases, it may be used to view certain vessels only, typically arteries. This type of scan is known as angiogram. You must specify if the patient will be scanned with (W/), without (W/O), or with and without (W/WO) contrast. How the contrast dye is given must also be specified, which can be orally, intravenously, or both orally and intravenously.If contrast is required, blood chemistries should be ordered prior to performing the scan to assess renal function (contrast dye cannot be given to patients with renal impairment or failure), and a pregnancy test should be ordered if the patient is a pre-menopausal female (radiation is harmful to refuses and should be avoided in pregnancy). Typically, remember to order these extra tests prior to imaging, but this is also an easy thing for a scribe to anticipate as an order.Ultrasound (US): Using sound waves deflected off of body structure to construct an image. This is similar to how dolphins and bats hunt using echolocation. Ultrasounds emit no radiation and are thus the safest imaging modality, especially during pregnancy.Magnetic resonance imaging (MRI): Radio waves and a magnetic field are used to make a 3D reconstruction of a region of the body. As discussed above in “special considerations”, MRI is used infrequently in the emergency department due to time and cost constraints.MRI can also be done with or without contrast, and thus the same considerations exist as mentioned above for CT scans.Nuclear medicine (NM): Uses radioactive compounds that adhere to certain body areas to visualize the radiation and, hence, that region of the body on imaging.Ventilation –Perfusion (VQ) scan – NM study that examines air and blood flow of the lungs.Other categories of tests: A broad category that includes any test used to better understand a disease process or the functionality of certain parts of the body. More concisely described as any additional testing that does not fit within the previous categories.EKG or ECG (electrocardiogram) – Measures the electrical activity of the heart.Biopsies (pathology analysis) – Determines the pathology of celss that were removed from a suspicious mass or lesion in order to help make a diagnosis.Pulmonary function testing (PFT) – Assesses lung functionality.EEG – Study of the electrical activity of the brain.Specific orders meant for other healthcare workers: Any orders that are directed at communication with a member of the healthcare team, such as nurses, techs, labs, radiology, and other providers.Nursing orders (with specific instructions free texted) – This could include applying dressings, wound care, ambulation of the patient, placing the patient on a monitor, patient education requests, setting up for a pelvic exam, obtaining vital signs and many more.Consult orders (with specific instructions free texted) – This could be to call for a consulation with a specialist (cardiology, general surgery, etc.) or with another department (lie social services or physical therapy).Order Panels: many facilities have created order panels. These are designed with the goal of facilitating easier access to the most frequently ordered tests for certain complaints. This aids in efficiency (not having to type in every test separately) and accuracy (not forgetting a test that should be ordered for a specific condition or complaint). Panels are always just starting points for ease of ordering and are generally modified on a case by case basis. They may be somewhat different from facility to facility, depending on local convention.Although a scribe never independently decides what things should be ordered for a patient, because many tests are ordered by protocol, a scribe may anticipate what the provider may order based on the patient’s history and exam. For example, if a patient has a cough, the provider will likely order a chest x-ray to rule out pneumonia.Here are a few possible examples of order panels. It is highly unlikely that any panels at your institution will be exactly like these, but the following list is a starting point for the beginner scribe.Abdominal panel – CBC, BMP, lipase, LFT, urinalysis. Imaging and pregnancy tests should be added depending on history and physician.Chest pain panel – CBC, BMP, troponin and repeat troponin after 120 minutes. EDG standard 12 lead, and portable chest x-ray. Medications and other tests often need to be added.Eye exam panel – Fluorescein ophthalmic strip, alcaine 0.5% ophthalmic solution, as well as slit lamp, woods lamp, and tono-pen to bedside. This equipment prior to the provider examination.Dyspnea panel – CBC, BMPprtable chest x-ray, and respiratory care per protocol. BNP (if possible heart failure), or EDG.ObGyn panel – Urinalysis with reflex microscopy, POC urine pregnancy, wet prep exam, STD panel PCR, pelvic exam set up and notification of physician.Psych panel – CBC, CMP, drugs of abuse urine, serum toxicology screen, urinalysis with reflex microscopy, ED contact order to crisis care consulatant.Sepsis panel – CBC, CMP, blood cultures, lactate/lactic acid, portable chest x-ray, urinalysis with reflex microscopy, urine culture. Fluids and antibiotics will likely be added.Weak and dizzy panel - EDG standard 12 lead, CBC, BMP, urinalysis with reflex microscopy, NPO nursing communication, bedside glucose, LFT, TSH with reflex free T4.Stroke non-hyperacute (over 3-4 hours post symptom onset) panel – CBC, BMP, bedside glucose, EDG standard 12 lead, CT head W/O contrast, NPO nursing communication, vital signs every 15 minutes, nursing swallow assessment, protime-INR.Stroke hyperacute (under 3-4 hours post symptom onset) panel – Activate stroke alert team, CBC, BMP, bedside glucose, EDG standard 12 lead, CT head W/O contrast stroke hyper acute, NPO nursing communication, take vital signs every 15 minutes, nursing swallow assessment, protime-INR, NIH stroke scale, partial thomboplastin (PTT).Trauma panel – EDG standard 12 lead, CBC, BMP, amylase, protime-INR, partial thromboplastin time, platelet function test-EPU, ethanol, drugs of abuse urine, urinalysis with reflex microscopy, bedside glucose, lipase, troponin, and repeat troponin after 120 minutes, type and screen, portable chest x-ray.DISPOSITIONTransition of care is a relatively new term to describe patient flow from one aspect of care to another. This could include transitioning from the doctor’s office to the emergency department, from the emergency department to inpatient, from inpatient to a specialist office, from a specialist office back to the family doctor, or other changes in a patient’s care team.It is important that communication is intact as a patient goes from care area to the next, so that the follow on provider does not have to repeat testing and the patient obtains the best outcome. The scribe obviously has an important function as the one responsible for documenting the information that will travel with the patient from one area of care to the next.In the emergency department, transition of care may look something like this:Scenario 1: Patient comes to the emergency department because they have a perceived emergency and is admitted to the hospital. They are cared for y the hospitalist (inpatient) or an other specialist (inpatient). The admitting physician may consult others from different specialties (inpatient). All of these providers will coordinate the patient’s care. They primary care provider, another specialist, skilled nursing facility, or long term acute care facility (outpatient).Scenario 2: Patient comes to the emergency department because they have a perceived emergency and is discharged. Generally referred back to their outpatient primary care provider (outpatient). May need to follow-up with a specialist (outpatient). Will eventually return to their primary care for routine follow-up (outpatient).Disposition is the decision regarding status change at the end of the patient’s visit in the emergency department. Patients cannot stay in the emergency department forever; thus, transition of care must take place. Patients will either be admitted, transferred, discharged, or they may leave against medical advice.Admission or transfer is the transition of apatient from the emergency department to a bed in the hospital or another facility. This occurs when the emergency room provider feels that the patient is not safe to go home and would benefit from additional medical evaluation and treatment in the hospital. Some hospitals have hospitalization for observation, which is a shorter stay meant for brief work-ups, or to “observe” the patient a while longer (usually less than 24 hours). Otherwise, patients are considered to be full admissions, which implies that they will stay in the hospital until deemed stable enough to be discharged for outpatient follow-up (usually the anticipated stay is longer than 24 hours).Patients may be admitted to different parts of the hospital. ICU (intensive care unit) admissions are reserved for patients needing critical care. Hospital admissions may be placed in a monitored bed (telemetry) or a regular bed. The patient may go to a hospitalist (general medical physician) or to a specialist such as a surgeon. Other types of physicians, typically specialists, may consult on patients during their hospital stay even if they don’t preform the admission themselves. This entails seeing the patient and giving advice in their area of expertise to the admitting physician.MEDICAL ABREVIATIONSYou will see many medical abbreviations in the electronic medical record, written by many different types of medical professionals. There are different and sometimes conflicting opinions on t heir use and place within the medical record, depending on who you talk to and what your job is. The guidelines in this handbook regarding the use of medical abbreviations are written in consideration of the following. As a psychometric technician, your primary function is to document a patient encounter within their medical chart. As such, pride should be taken in your work, and you should take the time to spell most things out. As a general rule, abbreviations are to be avoided. Some abbreviations can mean many different things. For example, “MS” can mean mental status, multiple sclerosis, morphine sulfate, or magnesium sulfate. This is why the psychometric technician should take the time to spell out the majority of the information contained within the note in order to avoid confusion. Keep in mind that other members of the healthcare team do not always spell things out, and therefore you should become familiar with abbreviations and their meanings so that you may communicate effectively. For example, nursing notes will often have many abbreviations that you will need to interpret. It is reasonable to follow these rules:As a general rule: always spell it out!You may use abbreviations only for those terms which are frequently used in your area of practice, which you know to be universally accepted and already in use by most others working in your area.When in doubt, refer to the first rule: spell it out!Medical diagnoses, lab tests and imaging, surgeries/procedures. These are frequently abbreviated, as many have long spellings are, for the most part, unanimously accepted as abbreviations. Only use these abbreviations if you have a compelling reason to do so, and you know that they are used commonly in your office or area of practice. Symptoms: All symptoms should be spelled-out. These are generally noaccepted as abbreviations, as some share acronyms with diagnoses (e.g. using “CP” for chest pain can easily be confused with the diagnosis cerebral palsy).Miscellaneous others: These are acronyms for phrases generally used in the notes of medical assistant, nurses, and other medical or laboratory technician (e.g. “ADL” for “activities of daily living”). You should know the meaning of these acronyms, but should again, generally spell these out unless there is a compelling reason to abbreviate and they are accepted in your area of work as the standard.As previously noted, these conventions may vary based on where you are working, and the provider with whom you are working. There will be times when shortcuts are needed in order to be efficient and you may be required to use abbreviations. You will have to learn as you go what is acceptable and what is not. Always remember to keep this phrase in mind; when in doubt, spell it out!ANATOMY GUIDEAs a psychological and psychiatric technician, there are a number of anatomical terms that are essential to learn, as they are useful both during the history and the physical exam. During the history, anatomical terms should be used to translate the patient’s lay terms for their discomforts/symptoms to medical jargon (e.g. using “periumbilical abdominal pain”, instead of “stomach pain around the navel”). Becoming familiar with the anatomical terms used during physical exam will aid the scribe in charting a physical exam accurately and efficiently, as told to them by the provider. Learning these terms prior to the first day on the job will allow the scribe to spend much less time looking-up the spelling of terms when they are busy with other duties. They will also not need to ask the provider to repeat parts of the physical exam that were missed. The following anatomical terms are organized similarly to the order seen in the sample physical exam template in Chapter 5. Some terms are defined, and others are accompanied by an image that illustrates the anatomical location. The terms that were selected for this chapter are some of the most common that you may encounter as a scribe. Other, more discreet terms were minimizing for the sake of reducing vocabulary volume. DIRECTIONAL TERMSThese are used to designate the position of something on the body in relation to other bodily structures. Notice that all of the directional terms are paired as opposites. For example, superior and inferior , anterior and posterior, proximal and distal, lateral and medial, and superficial and deep.When using directional terms, the observer’s point of view should be form the anatomic position, which is defined as the patient facing the examiner with the palms of their hands facing forward. Anatomic view of the observer can change the interpretation of the directional terms. For example, using anatomic position, which is the standard point of view, the sternum in anterior to the scapulae. If the patient is lying face-down and anatomic position is not used, the scapulae become anterior to the sternum, because the point of view of the observer is changed from posterior to anterior. This is why anatomic position is standard and always be used.Superior –closest to the top of the headInferior – closest to the bottom of the feetAnterior (ventral) – front of the bodyPosterior (dorsal) – back of the bodyProximal – closest to the center of the bodyDistal – further from the center of the bodyLateral – away from the midlineMedial – towards the midlineSuperficial – more externally locatedDeep – more internally locatedEENT (EYE, EAR, NOSE, THROAT)This is not a body system, per se, but rather a group of organs or body structures that are organized together. Sometimes these will be listed as “HEENT” (head, eyes, ears, nose, throat)The internal components of the eye can be viewed with the aid of an ophthalmoscope, which is a handheld device with a light. The examination of the internal eye structure is known as a funduscopic exam. Two internal structures that may be examined are the anterior chamber and the retina. The anterior chamber is a fluid filled space between the iris and cornea. The retina is located at the back of the eye, and is responsible for the converting light signals to electrical signals that are then sent to the brain for interpretation.ENDOCRINEThe endocrine system is a group of organs and glands that produce hormones, which are chemical messengers that travel through the blood to other parts of the body. Each hormone has a different function and target. The endocrine organs and glands are located in various places in the body.Thyroid gland – gland in the neck that produces thyroid hormones (T3 and T4)Parathyroid gland – four glands behind the thyroid gland in the neck that produce parathyroid hormoneAdrenal glands – glands on the top of the kidneys that produce many hormones, including adrenaline and steroidsPancreas – organ that produces glucagon/insulinLYMPHATIC SYSTEMThe lymphatic system is an interconnected series of vessels, tissues, and organs that filter the blood and contain lymphatic fluid, which houses various types of white blood cells that fight infection. Lymph nodes are areas of lymphatic tissue that can become swollen sometimes painful during infection, when inflammatory messengers and cells gather together in these locations. Lymph nodes can be palpated when they become enlarged.CARDIOVASCUALR SYSTEMThe cardiovascular system has multiple interconnected components, including the heart, vasculature (circulatory system), and blood. The left side of the heart contracts, producing a force that pushes oxygenated blood through out of the body via arteries, delivering oxygen to the cells of the body. Deoxygenated blood returns through the veins, first going through the right side of the heart from there it is pumped through the lungs to become reoxygenated.The heart is composed of four layers. The innermost membranous layer is known as the endocardium. The middle layer is the myocardium, which is composed of muscle cells that cause the heart to contract, pumping blood through the organ and into the arteries and veins. The outermost layers are the epicardium and the pericardium (or pericardial sac), which together form the pericardial cavity. The pericardial cavity is a space between the epicardium, the outer layer of the heart and the pericardial sac filled with pericardial fluid, which acts as a lubricant. The chambers of the heart are separated from each other, and from the vasculature, by flaps of tissue called heart valves. There are four heart valves. On the right side of the heart, there are two valves. The tricuspid valve separates the right atrium and the right ventricle, and the pulmonic (or pulmonary valve) separates the right ventricle fromt eh pulmonary artery, which directs blood to the lungs. On the left side of the heart, there are also two valves. The mitral (or bicuspid) valve separates the left atrium from the left ventricle, and the aortic valve separates the left ventricle from the aorta, which directs blood to the rest of the body. RESPIRATORY SYSTEMThe respiratory system is the “key player” in gas exchange, capturing oxygen during inspiration for the body to use, and releasing carbon dioxide, a waste product, during exhalation. Air first enters the body through the oral cavity and/or nasal passages. It travels down the pharynx in to the trachea, which is a hollow cartilaginous tube. The trachea divides into the left and right bronchi (bronchus, singular), which are also hollow tubes. The bronchi diverge into smaller tube-like bronchioles within the left and right lungs, and terminate at the alveoli, which are sacs of air in which gas exchange actually occurs.The diaphragm is a large muscle that causes the lung volume to expand and contract, with the aid of other muscles in the chest and abdomen. During inhalation, diaphragm increases lung volume, “pulling” fresh air into the lungs. During exhalation, the diaphragm decreases lung volume, “pushing” air with waste out of the lungs.DIGESTIVE SYSTEMDigestion is a long process with any participating organs. After entering the oral cavity, a food bolus passes through the esophagus, a hollow tube of smooth muscle, into the stomach. The stomach releases enzymes and acids and mechanically breaks-down the food into smaller molecules using peristalsis wave-like contractions of the muscle). The food bolus then passes into the small intestine, which is another hollow tube of smooth muscle that plays a large role in digestion. Enzymes and bile are released from the pancreas and gallbladder, respectively, into the small intestine to aid in digestion. The liver synthesizes the bile, which is stored in the gallbladder. The bolus then passes into the cecum of the colon, which is another hollow tube of smooth muscle that absorbs water from the digested contents. Then colon is divided into the ascending colon, transverse colon, and descending colon. The cecum comprises the first portion o f the ascending colon. After the bolus passes through the entire colon, the contents of the colon are emptied into the rectum as stool before being expelled through the anus.Several of the organs in the digestive system have functions other than aiding in digestion. The liver metabolizes wastes and toxins, participates in metabolic cycles like gluconeogenesis (creation of glucose), processes nutrients absorbed during digestion, and synthesizes cholesterols and blood clotting protein, among many others. The pancreas is both an exocrine and an endocrine organ. Not only does it synthesize enzymes for digestion, it also participates in endocrine regulation of blood glucose.GENITOURINARYThe genitourinary system is a combination of both the urinary system and the male and female reproductive systems.Urinary system: The urinary system filters the blood to regular electrolytes and excrete waste products and extra fluids from the body. The two kidneys (named so because of their resemblance to kidney beans), are located in the posterior portion of the pass the waste products and excess fluid into the ureters ars urine. The ureters are hollow tubes that drain the urine into the urinary bladder, which stores the urine until is expelled through the body via the urethra, another hollow tube.INTEGUMENTARYThe skin is the largest organ of the body and is composed of many layers and types of cells. In the scope of a scribe’s role, there are only two essential anatomical components that need be learned. The epidermis is the outermost layer of skin. The dermis is located below the epidermis and contain blood/lymph vessels, glands and hair follicles. Deep the dermis is the subcutaneous tissue.MUSCULOSKELETALTerms of movement: Describe movement of a body part, typically with the aid of one or more joints. As with “directional terms’, these are also paired as opposites. For example: flexion and extension, dorsiflexion and plantarflexion, abduction and adduction, medial and lateral rotation, supination and pronation, inversion and eversion, elevation and depression.Skeletal System: The skeletal system is composed of 206 bones that are positioned symmetrically. In other words, the body is a mirror image of itself. The skeleton is further classified into the axial skeleton and the appendicular skeleton. The axial skeleton comprises the “centralized component including hte skull, vertebral column, sternum, and ribs. The appendicular skeleton comprises the “appendage” of the skeleton, which includes everything that is not classified as axial.NERVOUS SYSTEMThe nervous system can be thought of as the “command center” of the body. Signals received from anywhere in the body are interpreted by the nervous system and a response is elicited. The nervous system is separated into two components: central nervous system (CNS) and peripheral nervous system (PNS). As the nomenclature implies, the central nervous system comprises those components that are central, such as the brain, spinal cord, and other affiliate structures. The peripheral nervous system comprises the peripheral components that extend elsewhere in the body.MEDICAL TERMINOLOGY INDEXThere is a great deal of medical terminology that is useful to know as a medical scribe. Having a comprehensive background in vocabulary will enhance both the quality and completeness of the history, the review os systems, and physical exam, in addition to greatly improving the scribe’s efficiency in completing the chart. The terms listed in this chapter are a good starting point for the emergency department scribe, but this is by no means a comprehensive list. There are many terms that are specialty-specific that are not covered in this text.This chapter is organized as a system-based approach to medical terminology. Within each system, the terms are further subclasses in the following order:Review of systems: Patients often describe what they are feeling or experiencing in the way that makes the most sense to them. It is one of the scribe’s biggest roles to translate the patient’s interpretation of their symptoms into “medical speak.” For example, if a patient says they have a nose bleed, the scribe should document “epistaxis”. Knowing symptom terminology, and the lay description associated with the medical term, will be one of the most useful tools for a scribe to use while constructing the history.In the text, symptoms that can be placed in multiple systems are underlined, and the alternate systems in which they can be placed are listed in parentheses. There may also be other possible locations for some of these symptoms that are not mentioned here. Physical exam: A more experienced scribe may be able to identify specific tests performed during the physical exam, and thus may chart the finding without being asked. To do this they may prompt their provider to confirm if the test was “positive’ or “negative,” or ask for any additional comments. This will help the provider become more efficient and will also result in more accurate and timely documentation. Oftentimes, this level of knowledge will come with time and familiarity with the provider. However, having a general understanding of the different things that may be seen or elicited on physical exam, and in which system they belong, is a great tool for a scribe to have. Signs (physical findings) may at times be appropriately placed in a different body system than what is listed, but less often than in the review of systems.Procedures: Types of procedures differ between the many specialties of medicine. Most of the procedures listed below are not performed in the emergency department. However, becoming familiar with procedure names and using these in lieu of the lay term equivalents will produce a more professional sounding chart. For example, a patient may say that they had their gallbladder removed. This should be documented as a “cholecystectomy.”Clinical impressions: It is not a scribe’s duty to diagnose, nor manage, any medical condition. Nonetheless, familiarity with frequently encountered clinical impressions or diagnoses will aid the scribe in identifying the medical conditions that a patient may be describing as part of their medical history. For example, if a patient says they have “high blood pressure,” the scribe should document “hypertension.” Typically, the provider is able to assist with identifying the diagnoses, needing to look them up. Having said this, do not spend a great deal of time trying to learn and understand all of these medical conditions. Rather, have a general understanding of each medical condition, and known how to spell it out. CONSTITUTIONAL:REVIEW OF SYSTEMSAnorexia (GI, Endocrine) – loss of appetiteChills – involuntary shiveringDizziness (Neurologic, Cardiovascualr ) – sensation that the room is spinning (should be placed hre if unsure of cause)Falls – mechanical (as in ‘slip’ or ‘trip’) or due to dizziness, palpitation, chest pain, etc.Fatigue (Endocrine) – sensation of feeling excessively tiredFever – a temperature greater than 100.4F (38C), by definitionHot flash (GU, Endocrine) – episodes of feeling warm and sweatyLethargy – excessive fatigue and inactivityMalaise – feeling generally unwellPolyphagia (Endocrine, GI) – excessive hungerRecent illnesses – any recent illnesses (e.g. upper respiratory infection)Somnolence – sleepinessSubjective fever – feeling warm without having taken a temperaturePHYSICAL EXAMAsthenic – appearing weakCachectic – generalize dbodily wastingDisheveled – appearing not well put togetherWell developed well nourished (WDWN) – appearing ina good state of health and nutritionHENT (HEAD, EAR, EYE, NOSE, THROAT)REVIEW OF SYSTEMSBlurred vision – loss of visual clarityCongestion – swelling and/or irritation of the nasal tissuesConjunctival injection – eye rednessDeafness (Neuro) – complete or partial hearing lossDentalgia/odontalgia – tooth painDiplopia (Neuro) – seeing doubleHard of hearing (Neuro) – difficulties hearingHead injury – any trauma to the face or skullHead pain – pain to any part of the face or skull (note headaches)Ocular angiodemea – eye swellingOcular drainage – any abnormal fluid or discharge from the eyeOropharnygela angiodemea – lip or throat swellingOtalglia – ear painPost nansal drainage – mucus drainage down the throatRhinorrhea – runny noseSinus pain/pressure – sensation of facial pain or pressureTinnitus (Neuro) – hearing sound (usually ringing) when none is presentVoice hoarseness – changes in the sound of voiceXeropghthalmia – eye drynessXerostomia – mouth drynessPHYSICAL EXAMApthae – oral ulcersAtraumatic – head without injuryBattle’s sign -bruising over the mastoid process of the skullCaries – tooth decay (cavities)Cataract – clouding of the lends in the eyeCerumen – ear waxConjunctival injection – redness of the conjunctivaEdentulous – toothlessnessExtraocular muscles intact (EOMI) – examination of the six eye musclesExudates – pustular patchesGingivitis – gum inflammationGlaucoma – elevated intraocular pressuresHemotympanum – blood in the middle ear (behind the tympanic membrane)Mallampati score – assessment of the oropharynx to predict difficulty of intubationNormocephalic – normal appearing headNystagmus – voluntary or involuntary eye movementPupils equal, round, reactive to light & accommodation (PERRLA) – examination of pupil functionRaccoon eyes – bruising around both eyes resembling a raccoonScleral icterus – yellow discoloration of the conjunctiva (as ina jaundiced individual)Septal deviation – displacement of the nasal septumSeptal hematoma – collection of blood in the septumStrabismus – inability to direct both eyes towards the same point simultaneouslyTonsillar enlargement – swelling of the tonsils (also termed “hypertrophic”)Uvular deviation – uvula that has moved from the midlineUvular enlargement – swelling of the uvulaPROCEDURESDental extraction – removal of teethFundoscopy – using an ophthalmoscope to examine the fundus of eye and other structuresMyringotomy – small incision in the tympanic membrane to relieve pressureSeptoplasty – surgically correcting the nasal septumTonsillectomy and adenoidectomy (T&A) – removal of the tonsils and adenoidsTurbinectomy -removal of the nasal turbinatesTympanostomy tubes – tubes place din the tympanic membrane to prevent fluid accumulationCLINICAL IMPRESSIONS/DIAGNOSESConjunctivis (pink eye) – conjunctival inflammationIritis – uveal inflammationKeratitis – corneal inflammationOnychomycosis – fungal infection of the nailOtis externa (aka swimmer’s ear) – inflammation of the outer ear and/or ear canalOtis media – inflammation in the middle earRetinal detachment – retina separate from support tissues Retinitis – retinal inflammationPeriodontitis – periodontal inflammationPeritonsillar abscess – collection of pus around a tonsilPharyngitis – pharynx inflammationSialolithiasis – salivary stones ina salivary glandTonsillitis – tonsil inflammationTracheitis – trachea inflammationUveitis – uveal inflammationHEMATOLOGIC/LYMPHATICREVIEW OF SYSTEMSBruising (skin) – blue, purple, yellow, or green discoloration usually due to traumaHematemesis (GI) – vomiting bloodHematochezia (GI) – stools with bright red bloodHematuria (GU) – blood in urineHemoptysis (Respiratory) – coughing bloodLymphadenopathy – swollen lymph nodesLymphatic streaking or lymphangitis – red streaking, normally up an extremity, due to infectionMelena (GI) – black and tarry stoolsPHYSICAL EXAMHematoma (Skin) – collection of blood within the skinLymphadenopathy – swollen lymph nodesLymphangitis – inflammation of lymphatic vessels that look like streakingLymphedema – extremity swelling from damage to the lymphatic systemPROCEDURESBone marrow biopsy – analysis of bone marrowCLINICAL IMPRESSIONS/DIAGNOSESAcquired immunodeficiency syndrome (AIDS) – progression of HIV with WBC destructionAnemia – decrease in the number of RBCs or hemoglobinDeep vein thrombosis (DVT) – venous blood clot, usually in the extremitiesHuman immune deficiency virus (HIV) – virus that destroys WBCs, causing immune deficiencyLeukemia – cancer of the blood/bone marrowLymphoma – group of blood cell tumors that develop from lymphatic cellsLeukocytosis – increase in the number of WBCsPolycythemia – increase in the number of RBCsThrombocytosis – increase in the number of plateletsLeukopenia – decrease in the number of WBCsPancytopenia – decrease in the number of RBCs, WBCs, and plateletsThrombocytopenia – decrease in the number of plateletsENDOCRINEREVIEW OF SYSTEMSAlopecia – hair lossAmenorrhea (GU) – absence of mensesAnorexia (Constitutional, GI) – loss of appetiteFatigue (Constitutional) – sensation of feeling excessively tiredHot flash (Constitutional, GU) - episodes of feeling warm and sweatyPalpitations (Cardiovascular ) – abnormal heart beat (e.g. fast, irregular, hard, racing, etc.)Polydipsia – excessive thirstPolyuria (GU) – excessive urine productionTemperature intolerance – intolerance to hot/coldXerosis (integumentary ) – dry skinPHYSICAL EXAMHirsutism – excessive hairiness on womenHyperpigmentation – darkening of an area of skin or nailsThyromegaly – thyroid gland enlargementPROCEDURESParathyroidectomy – removal of parathyroid glandsSplenectomy – removal of the spleenThyroidectomy – removal of the thyroid glandCLINICAL IMPRESSIONS/DIAGNOSESAddison’s disease – adrenal glands do not produce enough hormonesCushing’s syndrome – disorder caused by prolonged cortisol exposureDiabetes insipidus (DI) – excessive thirst and secretion of large amounts of urineDiabetes mellitus (DM) – high blood glucose over a prolonged periodGoiter – swelling of the neck due to thyromegalyGraves’ disease – autoimmune disease affecting the thyroid and causing hyperthyroidismHypercalcemia – elevated blood calcium (Ca++)Hypocalcemia – low blood calcium (Ca++)Hyperglycemia – elevated blood glucoseHypoglycemia – low blood glucoseHyperthyroidism – excessive production of thyroid hormoneHypothyroidism – thyroid hormone deficiencyOsteopenia – low bone mineral density, not to the point osteoporosisOsteoporosis (OP) – decreased bone density that increases risk of fractureThyroid storm – complication of hyperthyroidismCARDIOVASCULARREVIEW OF SYSTEMSBradycardia (slow pulse) – heart rate below 50 bpmChest Pain (Musculoskeletal) – sensation of chest discomfort, pressure, heaviness, etc.Dizziness (Neurovascular, Constitutional) – sensation that the room is spinning (should be placed here if associated with chest pain)Dyspnea (Respiratory) – shortness of breath with exertionExtremity swelling/peripheral edema (Extremities) – collection of fluid in any extremityHigh blood pressure – blood pressure above 120/80Orthopnea (Respiratory ) – shortness of breath that worsens lying supinePalpitations (Endocrine) – abnormal heart beat (e.g. fast, irregular, hard, racing, etc.)Paroxysmal nocturnal dyspnea (PND) (Respiratory) – sudden awakening at night with dyspneaSyncope – brief loss of consciousnessTachycardia (rapid pulse) – heart rate above 100 bpmPHYSICAL EXAMBradycardia - slow heart rate (below 50bpm)Bruit – abnormal sound of arterial blood flow due to a partial blockageEdema – swelling of various parts of the body due to water retention (especially the legs)Gallop – extra heart sound (S3 or S4, in addition to the normal S1 and S2)Hepatojugular reflux (HUR) – jugular distension elicited by applying pressure to the liverJugular veirn distension (JVD) – distension of the internal jugular vein on either side of the neckMurmur – abnormal heart sound caused by blood flowing across an abnormal valvePericardial friction rub – Velcro-like heart sound heard when there is excess fluid in the pericardial sacTachycardia – elevated heart rate (above 100 bpm)Telangiectasia – small dilated blood vessels near the surface of the skin and mucous membranesVaricous veins – veins that have become enlarged and tortuousVenous stasis – poor blood flow that causes chronic discoloration/skin changes to the lower legsPROCEDURESAblation –chemical or electrical termination of a faulty electrical pathway in the heartAngiography – using dye and x-0rays to visualrize blood vessels and organsCardiac catheterization – inserting a catheter into the heart for diagnosis and/or interventionCardiac stents – hollow tubes placed into the coronary arteries to keep them openCardioversion – using drugs or electricity to convert an irregular rhythm into normal sinus rhythmCoronary artery bypass graft (CABG) – heart bypass ot restore blood flow to an obstructed areaEchocardiogram – ultrasound of the heartElectrophysiology (EP) study – testing the electrical conduction system of the heartEndarterectomy – removal of plaques from the lining of an arteryHickman catheter – venous catheter inserted at the base of the neckHolter monitor – portable device that continuously monitors the electrical activity of the heartImplantable cardiac defibrillator (ICD) – performs heart cardioversion, defibrillation and pacingPICC line – tube inserted into any extremity vein for long term antibiotic therapySclerotherapy – injection into blood vessels to shrink themStress test – measures the heart’s ability to respond to external stressTransesophageal echocardiogram (TEE) – ultrasound of the heart throught the esophagusVelvuloplasy – hear tvalve repairVena cava (Greenfield) filter – implanted in the inferior vena cava to trap emboli and prevent pulmonary embolismCLINICAL IMPRESSIONS/DIAGNOSESAbdominal aortic aneurysm (AAA) – localized enlargement of the abdominal aortaAneurysm – bulge in the wall of a blood vesselAngina – chest pain with a cardiac etiologyAppendicitis – appendix inflammationArrhythmia – irregular heartbeatAtherosclerosis – arterial wall thickening due to plaque formationAtrial fibrillation – arrhythmia with a rapid and irregular heartbeatAtrial flutter – arrhythmia of the heart’s atriaCardiac arrest – failure of the heart to contractCardiomyopathy – pathology of heart muscleCongestive heart failure (CHF) – heart cannot effectively pump bloodCoronary artery disease (CAD) – disease of any of the arteries of the heartDysrhythmia – irregular heartbeatEndocarditis – inflammation of the endocardiumHyperlipidemia (HLD) – elevated blood cholesteraol and/or triglyceridesHypertension (HTN) – continually elevated blood pressureHypotension – low blood pressureMyocardial infarction (MI) – blood flow is blocked ot part of the heart causing tissue deathMyocarditis – inflammation of heart musclePericardial effusion – accumulation of fluid in the pericardial cavityPericarditis – inflammation of the pericardiumPeripheral artery disease (PAD) – narrowing of the extremity arteries that limits blood flowPeripheral vascular disease (PVD) – narrowing of the extremity vasculature that limits blood flowSick sinus syndrome (SSS) – arrhythmia caused by malfunction of the sinus nodeSupraventricular tachycardia (SVT) – improper electrical activity causing a rapid arrhythmiaValvular disease – disease of any heart valveVasculitis – inflammation of the blood vesselsRESPIRATORYREVIEW OF SYSTEMSApnea – cessation of breathingCough – productive (with sputum) or nonproductive (without sputum)Cyanosis (Skin) – bluish discoloration often due to low blood oxygenDyspnea (Cardiovascular) – shortness of breath with exertionHemoptysis (Hematologic ) – coughing bloodOrthopnea (Cardiovascular) – shortness of breath that worsens when lying flatParoxysmal nocturnal dyspnea (PND) (Cardiovascular) – sudden awakening with shortness of breathPlatypnea (Cardiovascular) – shortness of breath that worsens when sittingPleuritic chest pain (Musculoskeletal ) – chest pain with inspirationPosttussive chest pain (Musculoskeletal) – chest pain after coughing Singultus (Neuro) – hiccoughsSternutation – sneezeWheezing – whistling sound produced during expirationPHYSICAL EXAMAcidosis – increased acidity (H+) of blood/tissuesAlkalosis – decreased acidity (H+) of blood/tissuesArterial oxygen saturation (SAQ2) – percent of oxygen dissolved into arterial bloodBradypnea – slow breathing rateClubbing – club-shaped nail deformity associated with pulmonary diseaseCyanosis – blue or purple discoloration of the skin from hypoxiaEgophony – increased resonance of voice sounds during auscultationHypercapnia – elevated blood carbon dioxideHypercarbia – elevated blood carbon dioxideHyperventilation – rapid breathing rate that decreases blood CO2Hypoxia – oxygen deprivationPectus excavatum – congenital depression of the sternumRales – clicking, rattling, or crackling noises during inhalationRhonchi – coarse rattling respiratory sounds caused by secretions within the lungsStridor – high pitched breath sound heard during inspirationTachypnea – rapid breathing rateTracheal deviation – tracheal displacement from normal positionWhispered pectoriloquy – magnified volume of whispering during auscultation of the lungsPROCEDURESBi-level positive airway pressure (bi-PAP) – ventilation that reduces work of breathingBronchial lavage (BAL) – fluid is injected into a part of the lung and collected for examinationBronchoscopy – endoscopic visualization of the airwaysContinuous positive airway pressure (C-PAP) – ventilation that keeps airways openExtubation – removing a tube from the tracheaLobectomy – surgical removal of alung lobeLung transplant – diseased lungs are partially or totally replacedLung volume reduction surgery (LVRS) – removing dmaagaed parts of the lungsPulmonary function test (PFT) – evaluation of repiratory system functionSpirometry – testing of the ability to move air through the respiratory system quicklyThoracentesis – hollow needle inserted to the thorax to remove fluid or pus from the pleural spaceThoracotomy – incision into the pleural space to access the thoraxCLINICAL IMPRESSIONS/DIAGNOSESAcute respiratory distress syndrome (ARDS) – fluid accumulation in alveoli, causing collapseAspiration – foreign materials are trapped within the bronchial tree or lungs with inspirationAsthma – long term inflammatory disease of the airwayBronchitis – inflammation of the bronchi of the lungsBronchospasm – constriction of muscles in the bronchiolesInterstitial lung disease (ILD) – lung diseases causing scarring lung tissueLaryngitis –inflammation of the larynxLaryngospasm – vocal cord spasm causing difficulty breathing/speechObstructive sleep apnea (OSA) – intermittent airflow blockage during sleepPleural effusion – fluid accumulation in the pleural cavityPneumonia – inflammation of alveoli causing them to fill with fluidRespiratory failure – inadequate gas exchange in the respiratory systemNERVOUSREVIEW OF SYSTEMSAlertness – awake and aware of person, place, and timeAmnesia – memory lossAnesthesias – numbnessAphasia – in ability to express speechDeafness (HENT) – complete or partial hearin glossDiplopia (Eye) – seeing doubleDizziness (Constitutional, Cardiovascular) – sensation that the room is spinningDysesthesias – abnormal and often painful sensationFacial droop – unilateral facial weaknessFecal incontinence (GI) – involuntary bowel movementFocal neurologic deficit – acute changes in neurologic function that affects specific areas of the bodyHard of hearing (HENT) – difficulties hearingHeadache (HENT)- discomfort or pain in any region of the headLightheadedness – feeling near syncopalParesthesia – tingling sensation (“”pins and needles”)Radicular symptoms (Extremities)- radiating pain down an extremitySaddle anesthesia – numbness of groinScintillating scotoma – visual light disturbances with light that preced a migraineSingultus (Respiratory) – hiccoughsUnilateral weakness – weakness of one sideUrinary incontinence (GU) – involuntary loss of urinary controlPHYSICAL EXAMAsterixis – tremor of the hand when the wrist is extendedAtaxia – poorly coordinated muscle movementsBrudzinski’s sign – chin to chest causes neck pain and the urge to draw knees upCranial nerve II-XII tests – exercises used to determine functionality of the cranial nerves Dix-Hallpike maneuver – a test to determine whether dizziness is the result of positional changesDysdiadochokinesia – impaired ability to perform rapid alternating movementFocal deficits – abnormal neurological component, especially unilateralGlasgow Coma Scale (GCS) – a score measuring a patient’s level of consciousnessKernig’s sign – straightening the knee causes pain in the neck and/or backNational Institutes of Health (NIH) Stroke Scale – quantification of damage caused by strokePronator drift – test using both hands held pronated to evaluate upper motor neuron diseaseRomberg’s sign – testing proprioception by asking the patient to stand with both eyes closedCLINICAL IMPRESSIONS/DIAGNOSESAlzheimer’s disease – neurodegenerative disease associated with plaques and tangles in the brainAmyotrophic lateral sclerosis (ALS; Lou Gehrig’s disease) – disorder of the neuronal deathCarpal tunnel syndrome – median nerve compression causing pain and paresthesias in the lateral hand and fingersCerebral contusion – brain bruiseCerebral edema- excess fluid in the intra/extracellular compartment s of the brainCerebral hemorrhage – intracranial hemorrhage within brain tissueCerebrovascular accident (CVA; stroke) – poor brain blood supply resulting in localized brain death or deficitEpilepsy- seizure disorderHerpes zoster (shingles) – reactivation of chickenpox virus along a nerve rootIntracranial hematoma – hemorrhage within the skullMeningitis – inflammation of the meningesMultiple sclerosis (MS) - demyelinating disease damaging the neuronal insulating coversParkinson’s disease – degenerative disorder of the CNS affecting the motor systemPeripheral neuropathy – damage to peripheral nerves causing sensory changes or painRadiculopathy – pain, weakness, or numbness radiating to any extremity from spinal nerve compression or dysfunctionSciatica – pain, weakness, or numbness radiating to a lower extremity due to nerve dysfunctionSeizure – episode of excessive neuronal activity resulting in jerking muscle activation or absence (sudden laps in consciousness/awarenessTransient ischemic attack (TIA) – transient lack of blood flow to the brain causing ischemiaVertigo – sensation that you or the object around you are moving when they are notPSYCHIATRIC – See protocols and reference materialREVIEW OF SYSTEMSAnger outbursts – episodes of angerAnxiety – feeling uneasyAuditory hallucinations – hearing things that are not thereDepression – having a depressed mood or loss of interest in abnormal activities for a prolonged period of timeHomicidal ideation – thoughts of homicideManic episodes – abnormally elevated arousal, affect, and energyNon-restorative sleep – waking up feeling unrefreshedParanoia – thought os suspicion or mistrust that can be unrealistic or unwarrantedSleep disturbances – any disruption in sleepSuicidal ideation – concern, thoughts about , or an unusual preoccupation with suicideVisual hallucinations – seeing things that are not therePHYSICAL EXAMAffect – sign of emotionMood – emotional stateJudgement – quality of thought and capability of making informed decisionsPROCEDURESElectroconvulsive therapy (ECT)- seizures are electrically induced to relieve certain psychiatric disturbancesCLINCIAL IMPRESSIONS/DIAGNOSESAnorexia nervosa – eating disorder characterized by low body mass and food restrictionAnxiety disorder – mental disorder characterized by anxiety and fearAttention deficit hyperactivity disorder (ADHD)- poor focus, excessive activity, or impulsivityBipolar disorder – mental disorder with periods of depression and elevated moodBorderline personality disorder (BPD) – pattern of impulsivity and inconsistent relationshipsBulimia nervosa – eating disorder characterized by binge eating and purgingDepression – recurrent and persistent feeling of a depressed mood or loss of interest in normal activitiesObsessive compulsive disorder (OCD) – obsessive need to repeatedly do thingsOppositional defiant disorder (ODD)- pattern of defiant behavior in a childPostpartum depression (PPD)- depression after childbirthPsychosis – having lost contact with realitySchizophrenia – abnormal social behavior and failureMEDICATION INDEXPsychiatric:Antidepressants:amitriptyline/Elavilpregabalin/Lyricaduloxxetine/Cymbaltamilnacipran/Savellavenlafaxine/Effexorparoxetine/Paxilfluoxetine/Prozacbupropion/Wellbutrincitalopram/Celexasertraline/Zoloftescitalopram/LexaproBenzodiazepiinesalprazolam/Xanaxclonazepam/Klonopinlorazepam/Ativandiazepam/Valiumtemazepam/RestorilCNS (central nervous system) stimulatorsmethylphenidate/Concerta or Ritalindextroamphetamine/Adderallamphetaime/VyvanseAntipsychoticshaloperiod/Haldolziprasidone/Geodonaripiprazole/Abilifyrisperidone/Risperadolquetiapine/SeroquelSedativeszolpidem/AmbienMiscellaneousvalproate/DepakotePsychiatric:Antidepressants:amitriptyline/Elavilpregabalin/Lyricaduloxxetine/Cymbaltamilnacipran/Savellavenlafaxine/Effexorparoxetine/Paxilfluoxetine/Prozacbupropion/Wellbutrincitalopram/Celexasertraline/Zoloftescitalopram/LexaproBenzodiazepiinesalprazolam/Xanaxclonazepam/Klonopinlorazepam/Ativandiazepam/Valiumtemazepam/RestorilCNS (central nervous system) stimulatorsmethylphenidate/Concerta or Ritalindextroamphetamine/Adderallamphetaime/VyvanseAntipsychoticshaloperiod/Haldolziprasidone/Geodonaripiprazole/Abilifyrisperidone/Risperadolquetiapine/SeroquelSedativeszolpidem/AmbienMiscellaneousvalproate/DepakoteAllergic:Antihistaminesdiphenhydramine/Benadrylhydroxyzine/Vistarilcetirizine/Zyrtecloratadine/Claritinfexofendadine/Allegraepinephrine/EpiPenAnti-inflammatoriesmontelukast/SingulairIntranasal steroidsfluticasone/FlonasePERTINENT QUESTIONSThis chapter is a very brief summary of some of the most common questions that may be asked for some of the most common chief complaints. While you are new to scribing, many of the questions asked may seem random or unrelated to the chief complaint. However if you have some idea of “what” may be asked and “why”, it is easier to both anticipate these questions and to organize them in a meaningful way in the history. The content of this chapter is by no means exhaustive, but rather a very basic list of considerations that will allow you to become more effective at constructing a history.This chapter is organized first by chief complaint. Alongside each chief complaint is a brief differential that a provider might consider during an encounter. A differential is a list of possible diagnoses generated based upon a patient’s chief complaint. The differential is typically narrowed down with the aid of additional history, physical exam findings, and testing, with the ultimate goal of identifying a final diagnosis.Each diagnosis in the differential is accompanied by a list of associated questions that are specific to that diagnosis. These que3stions may make that specific diagnosis less or more likely, so remember that documenting the “pertinent negatives” is equally important as documenting the positives. The associated questions are organized by the different components of the history: history of the present illness (HPI), review of systems (ROS), past medical history (PMHx), family history (FHx), social history (SHx), and past surgical history ({SHx) in parentheses, reasons why that component of the history may be important are explained.It is not necessary to memorize the differential of each chief complaint or any of the risk factors associated with certain diagnoses. Use this chapter merely as a guide to help you become a more effective and efficient scribe by learning to anticipate what may be asked by your provider.CHEST PAINDifferential: Think cardiac (myocardial infarction), pulmonary (pneumonia or pulmonary embolist), gastrointestinal (esophageal spasm or ulcer), musculoskeletal (rib injury or inflammation), skin (shingles).Cardiac (myocardial infarction):HPI: Pain is exertional, pressure-like, or may radiate to an arm or jaw.ROS: Nausea, diaphoresis, shortness of breath.PMHx: Hypertension, hyperlipidemia, diabested (risk factors for CAD), CAD (risk factor for MI).FHx: Coronary artery disease at a young age (rick factor for CAD.SHx: Smoking (risk factor for CAD).Pulmonary (pneumonia or pulmonary embolus):HPI: Pain is pleuritic or sharp (more frequent in pulmonary diagnoses).ROS: Cough, shortness of breath, fever (as in pneumonia or bronchitis).PMHx: Pulmonary issues like asthma or COPD (may explain a pulmonary etiology). Prior DVT or PE or hyperzoagulable state like cancer, factor V leiden, lupus, pregnancy (risk factors for PE).SHx: Recent prolonged immobilization like travel, surgery or illness (risk factors for PE); smoking (risk factor for infection.Gastrointestinal (esophageal spasm or ulcer).HPI: Pain is associated with swallowing.ROS: Acid-like taste in mouth (as in GERD/reflux)PMHx: GERD or ulcers (history of similar may explain current).Musculoskeletal (rib injury or inflammation):HPI: Pain is associated with movement and is alleviated with rest.ROS: Recent known trauma.Skin (shingles):ROS: Rash or burning sensation.PMHx: Chickenpos, shingles, or immunosuppression (risk factor for shingles).SHORTNESS OF BREATHDifferential: Think infection (pneumonia), chronic lung disease (COPD/emphysema), airway spas (asthma), heart disease (CHF), malignancy (primary lung or metastatic disease), hypercoagulable state (pulmonary embolism), or aspiration (foreign body in lungs).Infection (pneumonia):ROS: productive cough or fever (infectious).PMHx: Immunocompromise due to steroids, chemotherapy, or immunodeficiency (risk factors for infection).SHx: Exposure to infectious causes (risk factor for infection).Chronic lung disease (COPD/emphysema):HPI: Recent exposure to respiratory irritants like smoke or infection (worsens underlying disease).PMHx: COPD/emphysema (recurrent problem more likely).SHx: Smoking or occupation exposure (risk factors for chronic lung disease).Airway spasm (asthma):HPI: Recent exposure to a possible allergen (worsens underlying disease).ROS: Sneezing, watery or itchy eyes, rhinorrhea, or wheezing (allergic).PMHx: Asthma or known allergies (recurrent problem more likely).Heart disease (CHF):ROS: Orthopnea, leg swelling, or weight gain (seen in congestive heart failure /CHF).PMHx: CAD with MI, hypertension, hyperlipidemia, or diabetes (risk factor for CHF).FHx: CAD at a young age (rick factor for MI).SHx: Smoking or recreation drugs (risk factor for MI or CHF).Malignancy (primary lung cancer or metastatic disease):ROS: Unexplained weight loss, night sweats, or anorexia (often seen in cancer).PMHx: Cancer (metastatic disease more likely).SHx: Smoking (risk factor for malignancy).Hypercoagulale state (pulmonary embolism):HPI: Sudden onset.ROS: Pleuritic chest pain (hallmark of pulmonary embolism), unilateral leg swelling (possible sign of clot in the leg/DVT).PMHx: Prior DVT or PE or hypercoagulable state like cancer, factor V leiden, lupus, or pregnancy (risk factors for PE).FHx: Hypercoagulable risk (risk factor for DVT/PE).SHx: Recent prolonger immobilization like travel, surgery, illness (risk factor for DVT/PE).Medications: Hormones (hypercoagulability risk factor, anticoagulants (clotting less likely).Aspiration (foreign body in lungs):ROS: Fever or cough.PMHx: Stroke or Alzheimer’s dementia (difficulty swallowing, making aspiration more likely).BACK PAINDifferential: Think arthritis, malignancy (primary osteo or metastatic disease), abdominal aortic aneurysm, gynecologic source (tumors, pelvic inflammatory disease), muscual strain, spinal infection, or renal disease (kidney infection or stones).Arthritis:HPI: Chronic and gradual onset.ROS: Polyarticular involvement (as in generalized arthritis)PMHx: Arthritis (history of similar may explain current) or autoimmune disease (autoimmune disease often leads to arthritis).Malignancy (primary or metastatic disease):ROS: unexplained weight loss, night sweats (seen in cancer). Loss of bladder control, leg weakness or pain (if cancer impinges on lower spinal canal).PMHx: Cancer (relapse or metastasis more likely).FHX: Cancer (risk factor).Abdominal aortic aneurysm:HPI: Sudden onset, “tearing” in nature (classic presentation for dissecting aneurysm).ROS: Lightheadedness or syncope (hypovolemia), abdominal pain, or cold leg/foot (loss of peripheral circulation).PMHx: Longstanding hypertension (risk factor).Gynecologic (tumors, pelvic inflammatory disease):ROS: Abnormal vaginal discharge or bleeding.PMHx: Prior infection, ectopic pregnancy, endometriosis, or uterine fibroids (recurrent problem more likely).PSHx: Gynecologic malignancy or ovarian cyst surgery. Muscular Strain:HPI: Recent sports or work injury or other accident or trauma.ROS: Lack of other findings to indicate other causes (diagnosis of exclusion).PMHx: Other injuries to the same area (could indicate a weak or susceptible muscle).Spinal infection:HPI: Gradual onset (infections develop over time).ROS: Fever.PMHx: Immunocompromise due to steroids, chemotherapy, immunodeficiency disease (higher risk of infection).SHx: IV drug abuse (risk factor spinal abscess).Renal (kidney infection or stones):HPI: Sudden onset (kidney stone) or gradual (infection). Location is flank (not midline). Pain is constant and waxes/wanes in severity.ROS: Urinary symptoms or abdominal pain.PMHx: Kidney stones or UTIs (make recurrent issue more likely).ABDOMINAL PAINDifferential: think gallbladder, appendix, ulcers, intestinal cramps, liver disease, vascular problem (ischemia), urinary issues (infections, stones, obstructions), infectious diarrhea, autoimmune disease (Crohn’s or ulcerative colitis), skin disorder (shingles), intestinal obstruction (from tumor adhesions), or gynecologic issues (tumors, infections, ovarian cysts, ectopic or normal pregnancy, endometriosis).Gallbladder (stones or obstruction):HPI: RUQ pain radiating to the back/chest, symptoms triggered by fatty meals.ROS: Abdominal bloating.PMHx: Gallbladder disease or stones (recurrent problem more likely).Appendix (appendicitis):HPI: Gradual onset with migratory pain from per umbilicus to the RLQ (classis presentation).ROS: Low grade fevers.Ulcers:HPI: epigastric pain, intolerance to spicy food, relief with antacids.ROS: Dyspepsia, melena, “coffee ground” emesis (bleeding ulcers cause this).Intestinal cramps:HPI: Intermittent, severe, cramping abdominal pain in varying locations.ROS: Change in bowel movements, often constipation.Liver:HPI: Constant pain in the RUQ.ROS: Jaundice, fatigue, weight loss, anorexia, abdominal distension (ascites).PMHx: Hepatitis (risk factor for cirrhosis or recurrence).SHx: Alcohol use (risk factor for cirrhosis), IV drug use (risk factor for hepatitis C).Vascular issues (schemia):HPI: Severe pain or mild, intermittent pain (depends on degree of ischemia).PMHx: Diabetes, hypertension or other known vascular diseases (risk factor for vascular disease).Urinary (infections, stones, obstructions):ROS: Fever (infection), pain radiating to the back or flank (if kidney also involved), urinary symptoms such as burning, frequency or urgency, or inability to urinate.PMHx: Prostate problem (in men may lead to urinary retention/inability to urinate).Infectious diarrhea:ROS: fever, diarrhea, blood or mucus in stool, vomiting.SHx: Recent travels or suspicious foods (risk factor for exposure to infection).Autoimmune disease (Crohn’s or ulcerative colitis):HPI: RLQ pain common.ROS: Low grade fevers, diarrhea, bloody stools or stools with mucus.PMHx: Inflammatory bowel disease (recurrent problem more likely).Skin (shingles):ROS: Rash or burning sensation.PMHx: Chickenpox, shingles, or immunosuppression (risk factor for shingles).Intestinal obstruction (from tumor or adhesions);HPI: Generalized abdominal pain that is crampy in nature.ROS: No fever. Nausea, vomiting (may be food or feculent material), no recent bowel movement, weight loss, anorexia, abdominal bloating or distension (all suggest that food is not moving through the GI system).PMHx: Prior surgeries (lead to scarring/adhesions that can cause obstruction).Gynecologic (tumors, infections, ovarian cysts, ectopic or normal pregnancy, endometriosis).HPI: Lower abdominal pain that may be left, center, or right (ovarian cyst or ectopic).ROS: Last known menstrual period and normalcy of cycle, menorrhagia or unexpected weight changes (cancer), fever or chills (infection), abnormal discharge (infection), or breasts swelling and nausea (pregnancy).PMHx: History of STDs (risk of STC or ectopic pregnancy), or prior pregnancies.SHx: Number of sexual partners (risk of infection), use of birth control (pregnancy less likely).FALLDifferential: Think syncope (most likely cardiac but also dehydration, anemia, malnutrition or seizure), disequilibrium (intracranial hemorrhage, stroke, or inner ear problem), weakness (malignancy, dehydration, anemia, or stroke), mechanical fall, abuse, or infectious process.Syncope (most likely cardiac, but also dehydration, anemia, malnutrition, or seizures):HPI: Sudden, without prior warning (suggests cardiac) or gradual onset (may suggest dehydration, anemia, or malnutrition).ROS: Palpitations (drop in blood pressure), dizziness (loss of blood pressure from dehydration or anemia), shortness of breath (pulmonary embolism or MI), sensory changes (malnutrition can cause neurologic symptoms), tongue biting or urinary/stool incontinence (seizures, or time of last meal (hypoglycemia).SHx: Recreational drug use (can cause altered mental status with loss of consciousness, especially in the cases of an overdose). New medicine prescribed or change in dosage of medications (may cause a drop in blood pressure).Disequilibrium (intracranial hemorrhage, stroke, inner ear problem):ROS: Headache (intracranial bleed); visual changes, imbalance or abnormal gait (cerebellar issues); focal weakness (stroke); or tinnitus (inner ear).Weakness (malignancy, dehydration, anemia, or stroke):ROS: Weight loss or anorexia (malignancy), decreased fluid intake (dehydration), recent illness (dehydration), bleeding (anemia), or focal weakness (stroke).PMHx: Diabetes (risk factor for dehydration or stroke), known malignancy (recurrent problem is more likely), or malnutrition (risk for dehydration and general weakness from body “deconditioning”).Mechanical fall:HPI: Falls due to tripping, slipping, or stumbling.PMHx: Neurologic conditions (could cause difficulty with gait and thus creates a fall risk).Abuse:ROS: Recent injuries.SHx: Safety at home, “where” is home, and “who” are housemates or caregivers.Infection:ROS: Fever, urinary symptoms, cough, diarrhea, red skin (leads to weakness, increasing chance of falls).HEADACHEDifferential: Think migraines, tension headaches, intracranial hemorrhage, sinus problems, meningitis, or cancer.Migraines:HPI: Unilateral headache, similar to prior headaches.ROS: Photophobia, phophobia, nausea, vomiting, light flashes or other visual auras (often seen in classic migraines).PMHx: History of migraines (recurrent problem more likely).FHx: History of migraines (risk factor for migraines).Tension headache:HPI Bilateral headache, located frontally, radiating to the occiput.ROS: No focal complaints, such as unilateral extremity weakness or facial droop.Intracranial hemorrhage:HPI: Sudden onset (thunderclap), severe, triggered by another event, usually exertional (such as during sexual intercourse).ROS: Nausea, vomiting, focal weakness , dizziness, altered level of consciousness.Medications: Anticoagulation (bleeding more likely).Sinus problems:Headache is frontal, pressure-like, with sinus drainage often discolored.ROS: Fever. No associated neurologic deficits. PMHx: Allergies or prior sinusitis (recurrent problem more likely).Meningitis:HPI: Gradual onset of febrile illness that has progressed to headache and neck stiffness ( classic presentation). Meningitis vaccine (makes infection less likely).ROS: Fever, neck stiffness, rash, or altered level of consciousness.PMHx: Immuno-compromise due to steroids, chemotherapy, or immunodeficiency (more prone to infections).SHx: Exposure to meningitis (infection more likely).Cancer:HPI: Gradual onset, not relievable.ROS: Slow onset of neurologic findings such as focal weakness, confusion or somnolence.PMHx: Cancer (metastatic disease likely).TRAUMA:Differential: Think: why did this happen (was this caused by another medical issue), what is injured and will the patient require surgery. The “differential” for trauma is a little different than the other examples thus far. Some general questions that will arise in trauma are the following:Trauma (general):HPI: mechanism of injury (knife, gun, fall, or motor vehicle accident); use of seat belts or air bag deployment if MVA (suggest certain possible injuries); and last meal (an empty stomach is preferred before surgery to avoid vomiting and aspiration).Medications: Last tetanus shot (if open skin), blood thinners (bleeding may be more difficult to stop).SHx: Drug use (may affect mental status).EYE COMPLAINTSDifferential: Think glaucoma, amaurosis fugax (stroke warning), corneal abrasion, retinal detachment or vascular occlusion (central venous or arterial).Glaucoma:ROS: Eye pain, nausea or visual clouding.PMHx: Diabetes or prolonged steroid use (risk factors).Amaurosis fugax (stroke warning):ROS: Temporary loss of vision that is unilateral and painless.PMHx: Stroke, hypertension, or diabetes (risk factor for stroke).Corneal abrasion:HPI: Constant unilateral discomfort.ROS: Foreign body sensation, eye pain or discomfort, tearing, redness, photophobia, headache or blurred vision.SHx: Occupation or activities (risk for foreign body exposures).Retinal detachment:HPI: Onset after trauma (risk factor)ROS: Floaters, light flashes or “curtain” of visual field loss.Vascular occlusion:ROS: Vision loss; can be painful (venous) or painless (arterial).WEAKNESSDifferential: Think anemia, electrolyte disturbance, dehydration, cardiac problem, cancer, nutritional issue, renal disease, stroke or depression.Anemia:ROS: Hematochezia, melena, heavy menses, other bleeding, or shortness of breath (anemia).PMHx: Nutritional deficiency or blood thinners (bleeding more difficult to stop).SHx: Gastric bypass (malnutrition).FHx: Anemias or Mediterranean descent (certain gene-linked entities.Electrolyte disturbance:ROS: Nausea, vomiting, or diarrhea (loss of fluids and associated electrolytes.PMHx: Endocrine problems such as diabetes (alters electrolytes).Medication: Diuretic use (excretion of water can cause electrolyte imbalances).Dehydration:ROS: Nausea, vomiting diarrhea, or poor fluid intake.PMHx: Diabetes (excess glucose causes more water to be excreted in the urine).Cardiac problem:ROS: Chest pain, palpitations, unexplained nausea or dyspnea on exertion, leg swelling or orthopnea (heart failure). Low blood pressure readings at home.Nutritional issue:PMHx: Gallbladder or pancreatic problems, or cancer (all can lead to malnutrition).SHx: Weight loss programs or fad diets, or alcohol use.PSHx: Any kind of gastric bypass (can cause malnutrition).Renal disease:PMHx: Hypertension, diabetes, or recurrent kidney infections (risk factors for renal disease)Stroke:ROS: Focal weakness, headaches (mainly with cerebral bleeds), or altered mental status.Medications: Anticoagulation (less likely if blood is thin).Depression:ROS: Loss of interest in life, lack of participation in activities, history of suicidal thoughts, poor appetite or sleep hygiene, or worsening grades at school.FHx: Depression (risk factor for depression). ................
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