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by Timothy D. Conwell DC (Author)
THE CLINICAL PICTUREby Drs. Conwell & LehmanTick ... tick ... tick ... how many patients are waiting?As a health-care student or new practitioner, you work hard to refine your clinical skills, including the all-important history and physical (H&P) examination. You document your findings to help you diagnose your patient's problem and develop a treatment plan, and those records assist other health-care providers treating the patient. When care is holistic, integrated, and evidence-based, best-case practice requires careful documentation to increase good outcomes for patients. Meanwhile, the clock is ticking and more patients are waiting. THE CLINICAL PICTURE by Drs. Conwell & Lehman will help you improve your skill and efficiency in performing and documenting the initial H&P for patients presenting with neuromusculoskeletal conditions. Mastering the information in this concise and practical guide will: - Prepare you for board examinations that require knowledge in evaluating patients with neuromusculoskeletal conditions.- Improve your acumen and efficiency in acquiring and documenting complete information in a neuromusculoskeletal workup- Improve your ability to diagnose the majority of neurologic and musculoskeletal complaints of the neck, back, and extremities- Improve quality of care and patient outcomes in a patient-centered environment.The book includes illustrations to help you easily comprehend the material. Its three sections are History and Physical Examination, Narrative Report Writing, and Daily Record-Keeping. This comprehensive guide covers the following information: SECTION I thoroughly, yet succinctly, covers how to pull a comprehensive Medical History and perform a detailed Physical Examination of the neuromusculoskeletal system. - Medical HistoryThis section includes an extensive Outline Guide for quick reference and a comprehensive Confidential Patient History Questionnaire form. You will learn how to obtain and use the valuable historical information by incorporating the following acronyms: HPI, PMH, OPQRST, PSFH, ADL, ROS, and much more. The history section covers all the steps required to collect a detailed history from the patient.- Physical ExaminationThe emphasis is placed on the individual parts of the medical exam including general appearance, vital signs, neurologic evaluation (screening for lesions of the Central and Peripheral Nervous System), and orthopedic evaluation (inspection, palpation, ROM, provocative tests, peripheral vascular screen, non-organic physical signs). Chapters cover in detail Impression/Diagnosis, Treatment Plan, Outcome Assessment Tools, indications for Diagnostic Tests, descriptions and significance of the most common orthopedic and neurologic tests, and the commonly used medical abbreviations. SECTION II, Narrative Report Writing, includes a complete Narrative Report Outline Guide for quick reference. You will learn how to: - Use the key components of the medical narrative- Integrate information from the physical exam into the narrative report- Use appropriate medical phrasing and a precise writing style for the narrative report. - Detailed sample narrative reports from different medical specialties will help you apply the information in this section. SECTION III, Daily Record Keeping, thoroughly discusses: - The S.O.A.P. Note method for documenting daily office visit findings- Documentation required for medical necessity of the treatment provided- Communications with other health care providers- The problem-oriented medical information system PROMIS - The definition of Evaluation & Management (E&M) service codes- This section includes numerous detailed Daily Office Note (SOAP note) examples with accompanying appropriate E&M codes.
