Download CVCOM COMLEX 2-PE QUICK REFERENCE Start of 14

CVCOM COMLEX 2-PE QUICK REFERENCE
Start of 14-minute session announced
Targeted completion time (TCT) < 1 minute
Open wall unit and review:
Patient Data Sheet: Circle abnormal BP, pulse, and respirations to be repeated during exam
Ancillary provided data: EKGs, laboratory results, etc.
Enter the room
Stop a few feet inside the door, facing the patient
be addressed
TCT < 1 minute
Ask the patient how he or she prefers to
Maintain eye contact; Introduce yourself by name and title
Excuse yourself to wash your hands while explaining need to wash before touching the patient
Sit on the examination stool
History
TCT ~ 5 minutes
Ask “What brings you in today?”; “What may I do for you today”
Allow the story to develop and follow historical clues; Use open-ended questions
Maintain eye contact 50% of the time
Follow patient comments with humanistic statements about the patient’s work, family, job,
ADL’s
Fill in the spaces next to the associated letter in the mnemonic as history is obtained
Keep a running list of possible diagnoses as they enter the differential
Ask symptoms associated to rule in or out each possible diagnosis
When you believe the history is complete
Summarize the story with the patient
Return to blanks in the mnemonic to obtain skipped information
Continued
Physical Exam
TCT < 5 minutes
Ask the patient permission to start the examination (examine the patient)
Usually best to include cardiac and pulmonary examination with each case; may be short in
non cardiopulmonary case
Ask if each area encountered would be affected with the suspected diagnosis
Skip those areas not affected; include your osteopathic structural examination skills while
performing the physical examination
Examine in detail the primary absolute organ system affected inspection, auscultation,
palpation, percussion, osteopathic structural examination
Perform examination of adjacent areas with detail as needed
Perform limited examination of distant systems of possible involvement
Advise patient of any prohibited examinations (i.e., breast, rectal, or genital) and explain that
they would be recommended
2-minute warning: If you have not finished the exam, stop and proceed with the assesssment
Assessment: Provide the patient with the proposed diagnosis.
TCT < 1 minute
This is essentially a differential of the possible diagnoses related to the history, ROS, and
physical examination finding’ They should be listed in order of most likely diagnosis
Plan: Utilize MOTHRR mnemonic. Consider each component TCT ~ 2 minutes without OMM
Medications: Instruct patient on type of medication and how to take it; also list any
medications you may wish the patient to stop taking
OMM: If appropriate, offer OMM and perform (NO HVLA) and limit to 3 to 5 minutes
Testing: Advise patient of labs, imaging, or other testing being ordered; this must be specific
to lab types, diagnostic tests, and modalities (PT, OT, home exercise program)
Holistic/Humanistic
Advise patient of PRICE, work restrictions, diet changes, smoking cessation, preventive
medicine counseling (safe sex, condom us, immunizations)
Express concern over the condition. Offer to involve family members. Ask them if they can
complete the proposed treatment plan
Referrals: Advise patient if referrals are being made
Return: Advise patient of need for admission, or develop a finite follow-up plan for the office
and when to go to the ER
Ask the patient if he or she has any questions
Thank the patient, shaking hands
Exit the room
SOAP note documentation:
9-minute
Begin the SOAP note immediately upon exiting the room
DO NOT document any history or examination that should have been completed but that
was not.
Document: Date and time
Chief Complaint
S: CC and HPI: Paragraph form
History: Bulleted
O: Vitals and general survey; any repeated vitals
Systems by bulleted headings
A(D): Minimum of four diagnoses related to the chief complaint in order of likelihood
Notate less likely diagnoses by “rule out” or “doubt”
Secondary diagnoses last
P: MOTHRR Format
Meds: Minimally name the class. Provide name, dose, frequency, and instructions; meds to
discontinue as well
OMM: Techniques used
Testing: Imagining, laboratory, or other testing; be specific
Referrals
Return plan for office and ER if needed
Note any history, examination, or manipulation that should have been taken or performed,
but that was not done during the patient encounter.
Legible signature
Print name if not legible
If the end of session is announced at any time before you are finished, immediately stop and
put your pencil down.