Woman Well Visit
Woman Well Visit
Includes all of the information the patient tells you. Identifying data: Initials, age, race, gender, marital status. Name of informant, if not patient.
CHIEF COMPLAINT (CC): The reason for this health care visit. A statement describing the symptom(s), problem, condition, diagnosis, physician-recommended return, or other factors that are the reason for this patient visit (even if they bring no specific problem). If possible, use the patient’s own words in quotation marks.
HISTORY OF PRESENT ILLNESS (HPI): If the patient presents with specific problems, symptoms, or complaints, a chronological description of the development of the patient’s present illness from the first sign of each symptom to the current visit is recorded using the elements of a symptom analysis. Those elements are:
• Location: Where it started, where it is located now
• Quality: Unique properties or characteristics of the symptom
• Severity: Intensity, quantity, or impact on life activities; duration: length of episode
• Timing: When symptom started, frequency (patient’s “story” of the symptom), context (under what conditions it occurs)
• Setting: Under what conditions the symptoms occur, activities that produce the symptoms
• Alleviating and aggravating factors: What makes it better and/or worse, what meds have been taken to relieve symptoms, did the meds help or not, does food make symptoms worse or better
• Associated signs and symptoms: Presence or absence of other symptoms or problems occurring with their complaint; include pertinent negatives and information from the patient’s charts (e.g., lab data or previous visit information)
If the visit is for follow-up of chronic conditions, provide a description of their health from the previous visit to the present to assess the status of their chronic conditions (this information should replace the symptom analysis in patients with chronic conditions).
In the case of a well visit, describe the patient’s usual health and summarize health maintenance needs and activities.
PAST MEDICAL HISTORY (PMH)
Woman Well Visit
Current medications: prescription and over the counter
Appropriate immunization status
Previous screening tests result
Dates of illnesses during childhood (may not be very important in adults; exceptions may include rheumatic fever or chronic illnesses continuing into adulthood)
Major adult illnesses (include history of diabetes, hypertension, gastrointestinal diseases, pulmonary disease, cardiovascular disease, cancer, tuberculosis, sexually transmitted infections (STIs), HIV/AIDS, gynecological or urological problems, drug and/or alcohol abuse, and psychiatric illness)
Hospitalizations (reason, hospital, attending physician [if known])
Surgeries (include hospital and year)
FAMILY HISTORY (FH): Age and current health status or age at death and cause of death of each family member (parents, siblings, and children) are recorded. Occurrence within the family of illnesses of an environmental, genetic, or familial nature is recorded in family history. Ask about the presence in the family of any of the following conditions: asthma, glaucoma, myocardial infarctions, heart failure, hypertension, cancer, tuberculosis, diabetes, kidney disease, haemophilia, sickle cell trait or disease, psychiatric diseases, alcoholism allergies, family violence, mental retardation, epilepsy, and congenital abnormalities.
Record any specific diseases related to problems identified in CC, HPI, or review of symptoms (ROS).
SOCIAL HISTORY (SH): Record important life events: marital status, occupational history, military service, level of education. Record lifestyle and current health habits (maybe here or in ROS): exercise, diet, safety (smoke alarms, seatbelts, firearms, sports), living arrangements, hobbies, travel. Record religious preference relevant to health, illness, or treatment. Record habits: use of drugs, alcohol, and tobacco.
Resources: resources to pay for care, insurance, worries about the cost of care, history of postponing care.
REVIEW OF SYSTEMS (ROS)
Woman Well Visit
There are 14 systems for review. Record a summary for each system. Unexpected or positive findings need complete symptom analysis.
1) Constitutional symptoms: Overall health, weight gain or loss, ideal weight, fever, fatigue, repeated infections, ability to carry out activities of daily living.
2) Eyes: eye care, poor eyesight, double or blurred vision, use of corrective lenses or medications, redness, excessive tearing, pain, trauma, date and results of last vision screening or eye exam
3) Ears, nose, mouth, and throat: Ears: hearing acuity, exposure to high noise level, tinnitus, presence of infection or pain, vertigo, use of the assistive hearing device. Nose: a sense of smell, discharge, obstruction, epistaxis, sinus trouble. Mouth and teeth: use of oral tobacco or smoking cigarettes, last dental exam date and result, pattern of brushing and use of dental floss and fluoride toothpaste, dentures, bleeding of gums, sense of taste, mouth odor or ulcers, sore tongue. Throat: sore throat, hoarseness, dysphagia.
4) Cardiovascular: Exercise pattern to maintain cardiovascular health. History of abnormal heart sounds (including murmur), chest pains, palpitations, dyspnea, activity intolerance, usual blood pressure, ECG (date, reason), cholesterol level (date), oedema, claudication, varicose veins.
5) Respiratory: Exposure to passive smoke. History of respiratory infections, usual self-treatment, cough, last chest x-ray (date, result), exposure to tuberculosis (TB) and last TB skin test (date and result), difficult breathing, wheezing, hemoptysis, sputum production (character, amount), night sweats.
6) Gastrointestinal: Dietary pattern, fibre and fat in diet, use of nutritional supplements (vitamins, herbs), heartburn, epigastric pain, abdominal pain, nausea and vomiting, food intolerance, flatulence, diarrhea, constipation, usual bowel pattern, change in stools, haemorrhoids, jaundice.
7) Genitourinary: Nocturia, dysuria, incontinence, sexual practices, sexual difficulty, venereal disease, history of stones. Men: slow stream, penile discharge, contraceptive use, self-testicular exam. Women: onset, regularity, dysmenorrhea, intermenstrual discharge or bleeding, pregnancy history (number, miscarriages, abortions, duration of pregnancy, type of delivery, complications), menopause (if present, use of hormone replacement therapy), last menstrual period (LMP), contraceptive use, last pap smear (date and result), intake of folic acid.
8) Musculoskeletal: Exercise pattern, use of seatbelts, use of safety equipment with sports, neck pain or stiffness, joint pain or swelling, incapacitating back pain, paralysis, deformities, changes in range of motion of activity, screening for osteoporosis, knowledge of back injury/pain prevention.
9) Integumentary (skin and/or breast): Use of skin protection with sun exposure, self-examination practices in assessing skin, general skin condition and care, changes in skin, rash, itching, nail deformity, hair loss, moles, open areas, bruising. Breast: practice of self-breast exam, lumps, pain, discharge, dimpling, last mammogram (date and result).
10) Neurologic: Muscle weakness, syncope, stroke, seizures, paresthesia, involuntary movements or tremors, loss of memory, severe headaches.
11) Psychiatric: Nightmares, mood changes, depression, anxiety, nervousness, insomnia, suicidal thoughts, potential for exposure to violence.
12) Endocrine: Thyroid problems, cold or heat intolerance, polydipsia, polyphagia, polyuria, changes in skin, hair or nail texture, unexplained weight change, changes in facial or body hair, change in hat or glove size, use of hormonal therapy.
13) Hematologic/lymphatic: Bruising, unusual bleeding, fatigue, history of anemia, last HCT and result, history of blood transfusions, swollen and/or tender glands.
14) Allergic/immunologic: Seasonal allergies, previous allergy testing, potential for exposure to blood and body fluids, immunized for hepatitis B, immunosuppression in self or family member, use of steroids.
A concise report of physical exam findings
Woman Well Visit
1. Constitutional (VS: Temp, BP, pulse, height and weight); a statement describing the patient’s general appearance
3. Ear, nose, throat
9. Integument/lymphatic pertaining to each location
Results of any diagnostic testing available during patient visit.
List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.
Diagnosis must be codable (CPT codes).
Provide adequate information to justify ordering additional data (e.g., lab, x-ray).
Do not write that a diagnosis is to be “ruled out.” State the working definitions (symptoms, probable diagnoses) of patient problems in the following areas:
o Health maintenance
o Acute self-limited problems
o Chronic health problems
In cases where the diagnosis is already established, indicate whether the diagnosis has the following characteristics: improved, well controlled, resolving, resolved, inadequately controlled, worsening or failing to change as expected.
Note: Inadequately controlled chronic conditions should have a possible etiology written (e.g., exacerbation, progression, side effects of treatment) if known.
PLAN (P): (The plan should be discussed with and agreed on by the patient.)
The treatment plan includes a wide range of management actions:
Consultation requested and justification
Medications prescribed (name, dose, route, amount, refills)
Lifestyle modifications: diet, activity modification
Patient education and patient responsibilities (e.g., keeping food diary or BP record)
Patient counseling related to lab/diagnostic results, impression, or recommendations
Details concerning coordination of care: arranging and organizing patient’s care with other providers and agencies
Follow-up should be specified with time (in days, weeks, months) and/or circumstances of return or noted as PRN
Note: Number the plan to correlate with the problem list in the Assessment.
• Describe clinical hours and patient encounters
• Analyze learning through practicum experiences
• Analyze communication and feedback through practicum experiences
• Construct a history of present illness for a clinical patient
• Synthesize the assessment and diagnosis of patient health conditions
• Justify treatment options
• Construct a well-woman exam for a clinical patient
• Evaluate implications of additional patient factors that impact plan of care
Write an 8- to 10-page Comprehensive Well-Woman Exam that addresses the following:
• Age, race and ethnicity, and partner status of the patient
• Current health status, including chief concern or complaint of the patient
• Contraception method (if any)
• Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
• Review of systems
• Physical exam
• Labs, tests, and other diagnostics
• Differential diagnoses—PRIMARY DIAGNOSIS AND 2 MORE DIFFERENTIAL DIANOSIS
• Management plan, including diagnosis, treatment, patient education, and follow-up care
• Provide evidence-based guidelines to support treatment plan. Note: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care.