Hey everyone,
We're working on improving our gallery, and I want to get some feedback regarding the healthcare section.
We're breaking down each post into smaller, logical ones. I'd like to see what people think about how I'm splitting some of them up.
Here are three different posts I'm thinking about. For each, I've listed the titles and the snippets under each post.
Here are my questions for you:
1. Does the organization make sense? Would you change anything?
2. Do the titles make sense? Would you change them?
Symptom and treatment plans
I see that you were treated for a UTI with {note}{formmenu: name=UTIABx; multiple=yes; MacroBID; Bactrim; Keflex; Cipro; Augmentin; Vantin}{endnote: trim=yes} {=join(UTIABx, "BLAZE_AND")} in {note}{formmenu: January; February; March; April; May; June; July; August; September; October; November; December; Today; name=Months; multiple=yes}{endnote: trim=yes} {=join(months, "BLAZE_AND")} {cursor}.
Was that your last UTI?
{formmenu: redness; itchiness; discharge; crustiness in the morning; a feeling as if something is in the eye; blurred vision; an injury to the eye; dryness; eye pain; eyelid pain; eyelid swelling; bump on the edge of the eyelid; decreased vision; sensitivity to light; name=PosEyeSx; multiple=yes}
{note}Back Pain Red Flags:{formmenu: default=1. Location and history; 2. Numbness or weakness; 3. Incontinence; 4. IVDA; 5. F/C; 6. Immunesuppression; 7. Female < 50 yo CA / wgt loss; 7. Female > 50 yo CA / wgt loss; 7. Male < 50 yo CA / wgt loss; 7. Male > 50 yo CA / wgt loss; 8. Sleep at night; 9. Worsen/alleviateion triggers; 10. What have you tired; 11. What has helped in the past; name=condition}
{endnote: trim=right}
{if: condition="1. Location and history"; trim=yes}
I see you have back pain
What part of the back -- lower or upper (please be precise)?
When did this start?
Any fall or trauma?
Any heavy lifting?
Have you had similar pain before?
{elseif: condition="2. Numbness or weakness"; trim=yes}
Any numbness or tingling of either leg or foot?
Any weakness of either leg or foot?
{elseif: condition="3. Incontinence"; trim=yes}
Any incontinence of urine or stool?
{elseif: condition="4. IVDA"; trim=yes}
Pardon the personal question but do you self-inject drugs?
I ask because that can put you at risk of a spine infection which is an emergency
{elseif: condition="5. F/C"; trim=yes}
Any fever or chills?
{elseif: condition="6. Immunesuppression"; trim=yes}
Any possibility of immune-suppression?
Do you take steroids?
Do you take immune-suppressing drugs?
Do you have an risk of HIV?
{elseif: condition="7. Female < 50 yo CA / wgt loss"; trim=yes}
Have you ever been diagnosed with cancer?
Have you been losing weight unexpectedly
Are you up to date on cancer screenings: PAP smear?
{elseif: condition="7. Female > 50 yo CA / wgt loss"; trim=yes}
Have you ever been diagnosed with cancer?
Have you been losing weight unexpectedly
Are you up to date on cancer screenings: colonoscopy, mammogram, PAP smear?
{elseif: condition="7. Male < 50 yo CA / wgt loss"; trim=yes}
Have you ever been diagnosed with cancer?
Have you been losing weight unexpectedly
{elseif: condition="7. Male > 50 yo CA / wgt loss"; trim=yes}
Have you ever been diagnosed with cancer?
Have you been losing weight unexpectedly
Are you up to date on cancer screenings: colonoscopy and prostate exam?
{elseif: condition="8. Sleep at night"; trim=yes}
When is the back pain at its worst?
In the morning?
At the end of the day?
Can you sleep at night?
{elseif: condition="9. Worsen/alleviateion triggers"; trim=yes}
What makes the back pain worse?
What makes it better?
{elseif: condition="10. What have you tired"; trim=yes}
What have you done or taken to alleviate the back pain?
{elseif: condition="11. What has helped in the past"; trim=yes}
Have you had similar back pain in the past?
What worked to alleviate the pain?{endif: trim=yes}
Medical charts with basic information
Chief complaint: {formtext: name=chiefcomplaint}
S: {formparagraph}
The patient is a {formtext: name=age} y/o {formmenu: male; female} complaining of {formtext} for the last {formtext} {formmenu: days; weeks; months; years; hours; minutes}.
ROS: {formparagraph}
O: {formparagraph}
A: {formparagraph}
P: {formparagraph}
Patient is a G{formtext: name=Gravid}P{formtext: name=Parous} who presents to establish OB care.
Patient is {formtoggle: name=sure lmp; default=yes}sure of her LMP{endformtoggle}{formtoggle: name=unsure of lmp; default=no}unsure of her lmp{endformtoggle} LMP {note}{formdate: MM/DD/YYYY; name=date}{formtext: name=shifting; default=}{endnote: trim=right} EDD: {time: MM/DD/YYYY; at={=date}; pattern=MM/DD/YYYY; shift={=shifting}280D}
{formtoggle: name=multigravid; default=yes}Patient has a previous pregnancy history that is {endformtoggle}{formtoggle: name=uncomplicated; default=yes}uncomplicated. {endformtoggle}{formtoggle: name=complicated; default=no}complicated by {formparagraph: name=complications} {endformtoggle}.
Past medical history and past surgical history is reviewed. {formtoggle: name=significant for\ ; default=no}It is significant for {formparagraph: name=significant history}.{endformtoggle}
{formtoggle: name=transfer ob care; default=no}The patient transferred care from {formtext: name=previous doctor}. They report they have had {formmenu: default=prenatal labs; 1st trimester ultrasound\ ; 2nd trimester ultrasound; referral to MFM; oral glucose tolerance test; name=pregnancy care items; multiple=yes}.
{formtoggle: name=records received; default=no}Records have been requested and received.{endformtoggle}{endformtoggle}
Medical assessment notes
{note: trim=yes}Please enter the following information about the patient:
Age (number of years): {formtext: name=Age}
Sex: {formmenu: default=; female; male; name=sex}
{endnote: trim=left}
- The patient is a {=Age} year old {=sex}.
- The patient's chart was reviewed and reconciled as noted in the HPI
- The patient's lifestyle was reviewed for possible impacts on health. I identified and addressed any barriers to improved health, such as age, gender, ethnic background, and, racial identity. Status of advanced health care planning was reviewed.
- The patient's self-reported or lab-reported vital signs were reviewed.
- Information was provided regarding healthy lifestyle choices and vaccinations.
- Based on recommendations for all or almost all adults, the patient was:
Screened for depression, unhealthy alcohol use, smoking, and unhealthy drug use
Screened for hypertension or recommended to screen for hypertension
Offered screening for Hepatitis C and HIV
Counseled regarding advanced care planning, including advanced directives, and offered follow up for future discussion if desired.
Specific concerns for this patient, if any:
{formtoggle: name=BMI over 25; default=no; trim=right}- BMI between 25 and 30: The patient was offered screening for diabetes. The patient given information on healthy diet and exercise for prevention of diabetes.{endformtoggle: trim=left}
{formtoggle: name=BMI over 30; default=no; trim=right}- BMI over 30: The patient was offered screening for diabetes. The patient was given information on healthy diet and exercise for weight loss and reduction of risk of diabetes and cardiac disease. {endformtoggle: trim=left}
{formtoggle: name=Having more than 1 partner in 12 months; default=no; trim=right}{endformtoggle: trim=left}
{formtoggle: name=Requesting testing for sexually transmitted infections; default=no; trim=right}{endformtoggle: trim=left}
{formtoggle: name=Sexually active; default=no; trim=right}{endformtoggle: trim=yes}
{formtoggle: name=Unhealthy alcohol use; default=no; trim=right}- Unhealthy alcohol use: Depending on the patient's preference, the patient was encouraged to follow up with me, was referred to counseling, or was advised to seek an alcohol counseling/treatment program.{endformtoggle: trim=left}
{formtoggle: name=Concern of depression or anxiety; default=no; trim=right}- Concern of depression or anxiety: Depending on the patient's preference, the patient was encouraged to follow up with me or was referred to counseling.{endformtoggle: trim=left}
{formtoggle: name=Elevated blood pressure; default=no; trim=right}- Elevated blood pressure: the patient was encouraged to follow up with me.{endformtoggle: trim=left}
{formtoggle: name=Female with personal or family history of BRCA related cancer or of Ashkenazi Jewish Ancestry; default=no; trim=right}{endformtoggle: trim=left}
Testing or screening ordered during this visit:
{note: trim=right}{formmenu: Basic labs, including: CBC, CMP, Hemoglobin A1C, TSH, Lipids; Hepatitis B, Hepatitis C, HIV, Syphilis; Gonorrhea/chlamydia; Quantiferon Gold TB; Low dose CT screening for lung cancer; Ultrasound for AAA; BRCA testing; FIT, Cologard; Bone density scan; Mammogram; name=testing; multiple=yes}{endnote: trim=right}
{if: testing=}None{else}{=join(testing,", ")}{endif}
Referrals placed during this visit:
{note: trim=right}{formmenu: Behavioral Health; Gastroenterology for colonoscopy; OB/Gyn for women's health; name=referrals; multiple=yes}{endnote: trim=right}
{if: referrals=}None{else}{=join(referrals,", ")}{endif}
The patient was advised to follow up at least annually for preventive health care, sooner as needed for review of results or discussion of concerns raised.
The patient verbalized a clear understanding of my instructions and was agreeable with the plan.