Assignment

1. Choose a patient encounter that is either a follow up for a chronic illness, a well child check, or physical exam that includes preventive care. (i.e., hypertension, diabetes, breast cancer screening, etc)
2. Write up a complete history reflecting what a family physician is interested in reporting, including a social history. Remember your outline format used to write notes on patient encounters (ie., meds, allergies, FmHx, Soc Hx, etc) This is not necessarily the same note that you would write in this patient's chart, because someone who does not have the chart will evaluate it. Therefore, more detail is better than less. You may include details found in the chart that were not discovered in the actual visit-please underline that information so that it can be distinguished from other information in the note.
3. Include a focused physical exam in your note-do not reproduce portions of the physical exam that were not related to the patient's age or condition. You should be able to explain what you were looking for when you performed each section of the exam. This should be clearly documented either in a paragraph or in parentheses after the physical exam category. Remember that you may exclude a portion of the exam but you must justify why you did this.
4. Identify all the ICD-9 Codes for this note. Write the note first and then feel free to ask you preceptor to help you with the codes.
5. Write an assessment and plan including lab tests, imaging and management for the identified problems. This should reflect some critical thinking and application of evidence-based medicine principles discussed with your preceptor or investigated independently in the literature (I am interested in higher level evidence - NOT expert opinion or textbooks). Please be sure to include the specific lab test or medication or treatment and justify why this is the case. For example, just saying that you want to start Lipitor for elevated cholesterol is insufficient. Explain the target values you wish to achieve, and where this evidence comes from. You are encouraged to use number-needed-to-treat (NNT) and number-needed-to-harm (NNH). If specifying labs or imaging, please indicate a pretest and posttest probability if possible. (i.e., with the DVT case, why a d-dimer is ordered rather than a Doppler).
6. Choose an E&M code (level of service) for the visit. Include a justification in terms of the number of items, severity of condition, complexity of decision-making and/or time spent with patient for the code that you chose. Again, feel free to ask your preceptor for help.
7. Submit your write-up via Blackboard.