MSN 610: HEENT Written History and Exam Documentation

This criterion is linked to a Learning OutcomeProvider’s Name

1 pts

This criterion is linked to a Learning OutcomePatient’s Initials

1 pts

This criterion is linked to a Learning OutcomeDate of Exam

1 pts

This criterion is linked to a Learning OutcomePatient’s DOB & Age

2 pts

This criterion is linked to a Learning OutcomePatient’s Gender & Sexual Orientation

2 pts

This criterion is linked to a Learning OutcomeChief Complaint

1 pts

This criterion is linked to a Learning OutcomeHPI (onset, symptoms–location, quality, quantity, timing; setting, aggravating or alleviating factors, associated problems or symptoms)

5 pts

This criterion is linked to a Learning OutcomePMH: hildhood diseases, adult diseases/medical conditions, accidents/injury history, immunization history

5 pts

This criterion is linked to a Learning OutcomeAllergies (drugs, IV contrast, bandages, pollen, plants, food, animal, occupational)

3 pts

This criterion is linked to a Learning OutcomeCurrent medications

5 pts

This criterion is linked to a Learning OutcomeSocial History (smoking or tobacco use, ETOH, caffeine, substance abuse, education attained, occupation, marital status, children?, lifestyle/activity level, diet, sports/activities/leisure/hobbies)

10 pts

This criterion is linked to a Learning OutcomeFamily History: Parents, siblings, children, grandparents (include ages, chronic medical conditions, malignancies, hereditary diseases, causes of death and age at death if applicable, suicide?)

5 pts

This criterion is linked to a Learning OutcomeReproductive & Sexual Health: First day of LNMP if applicable, date of first menarche if applicable, GPTPAL (if applicable), Libido issues?, STI history, contraception?

5 pts

This criterion is linked to a Learning OutcomeReview of Systems (ROS): General: weight gain/loss, appetite changes, sleeping habits, fever, fatigue, weakness, general health

5 pts

This criterion is linked to a Learning OutcomeROS: Skin: color changes, rashes, sores, pain, pruritis, hemorrhages, hair loss/pattern, changes in nails

5 pts

This criterion is linked to a Learning OutcomeROS: HEENT: headache, migraine, vision changes, cataracts, diplopia, otalgia, otorrhea, hearing changes, rhinorrhea, epistaxis, sinus drainage/pain, sore throat, hoarseness, dental pain/missing teeth, jaw pain or clicking

10 pts

This criterion is linked to a Learning OutcomeROS: Breasts: discharge, pain, enlargement, lesions, galactorrhea

5 pts

This criterion is linked to a Learning OutcomeROS: Respiratory: Pleuritic pain, tachypnea, asthma/wheezing, bronchitis, COPD/SOB/wheezing, TB history/treatment, orthopnea, DOE, sputum production, hemoptysis

10 pts

This criterion is linked to a Learning OutcomeROS: CV: chest pain, palpitations, pedal edema, cyanosis, claudication, phlebitis, hypertension, orthostatic hypotension, dizziness

10 pts

This criterion is linked to a Learning OutcomeROS: GI: nausea, vomiting, diarrhea, anorexia, dysphagia, hematemesis, bloating, flatulence, abdominal pain, constipation, clay-colored stools, hemorrhoids, hematochezia, melena, jaundice, GERD/heartburn

10 pts

This criterion is linked to a Learning OutcomeROS: GU: urinary frequency, dysuria, nocturia, flank pain, hematuria, penile discharge/vaginal discharge, incontinence (and details of same if positive), urinary retention, UTI hx, STI hx, fertility/contraception/orgasms issues or treatment hx

10 pts

This criterion is linked to a Learning OutcomeROS: MS: muscle pain, joint pain, loss of function, decreased ROM, loss of strength, joint swelling, hx of fractures/dislocations, hx of trauma/surgeries, back pain

10 pts

This criterion is linked to a Learning OutcomeROS: Neuro: dizziness, headache, sleep changes, syncope/near-syncope, paralysis, paresthesia, hx of LOC, hx of seizures, hx of loss of bowel or bladder control, loss of memory

10 pts

This criterion is linked to a Learning OutcomeROS: Endocrine: polyphagia/uria, goiter, lethargy, hot/cold intolerance, nervousness, obesity, change in sex characteristics, amenorrhea, gynecomastia, flushing

10 pts

This criterion is linked to a Learning OutcomeROS: Psychiatric: anxiety, depression, hallucinations (specify if positive whether auditory, visual, gustatory, olfactory, command), suicidal ideation, hx of suicide attempt, hx of involuntary commitment, homicidal ideation, delusions

10 pts

This criterion is linked to a Learning OutcomePhysical Exam: VS (temp, HR, BP, RR, O2 sat)

5 pts

This criterion is linked to a Learning OutcomePhysical Exam: General: must be at least 3 items

5 pts

This criterion is linked to a Learning OutcomePhysical Exam: Head: skull, scalp, face–shape, size, profile, symmetry, pain, meningeal signs?

5 pts

This criterion is linked to a Learning OutcomePhysical Exam: Ears: Shape/symmetry of auricles, canals, TM, auditory testing (Weber, Rinne, whisper)

5 pts

This criterion is linked to a Learning OutcomePhysical Exam: Eyes: visual acuity, visual fields, symmetry, drainage, eye position and alignment, PERRLA?, EOMI?, ophthalmoloscopy (red reflex, optic disc, vessels, papilledema, hemorrhages, retinopathy?)

5 pts

This criterion is linked to a Learning OutcomePhysical Exam: Nose: external and internal, patent nares? drainage? sinus pain? turbinates? bleeding? olfacation?

5 pts

This criterion is linked to a Learning OutcomePhysical Exam: Throat/mouth: jaw motion, lips, salivary glands, cheeks, tongue, teeth, gums, oral mucosa, pharynx, tonsils, uvula, soft/hard palate

5 pts

This criterion is linked to a Learning OutcomePhysical exam: Neck: flexibility, shape, symmetry, goiter/thyroid, lymph nodes and name, trachea, auscultate carotids, JVD?

5 pts

This criterion is linked to a Learning OutcomeAssessment Statement: including at least 3 problems or education deficits with ICD 10 codes

Remember, this is where you discuss your findings both from the history and the physical exam, this is where you put your medical decision making–either why an intervention is needed or why there isn’t an intervention needed, it’s your “wrap up” as if you are talking to another medical provider. Include ICD-10 codes for each problem listed.

15 pts

This criterion is linked to a Learning OutcomePLAN: at least 3 steps to address the problem list

write here next to at least 3 problems what you would do to address these, recommend to the patient, educate the patient, refer out to specialist, run tests, prescribe medication, etc. You don’t have to do all of these, but you have to write next to each problem what you would do

15 pts

This criterion is linked to a Learning OutcomeYour signature and date

You have to sign every chart or documentation you do as a provider, and you have to write the date you sign it.

5 pts

Total Points: 226