Ortho-Preferred

Clinic Notes: Main Page

 How to Build a History Template for Team Wheeless.

   Check the insurance situation, and follow Rick's guidelines for being seen at OSNC.

  Must call from a phone or cell phone that comes up as OSNC
  Check the website intake form to see if any of this information is already given.  If so try to look at it so that the interview
  goes faster.

  Say good afternoon Ms Jan Doe.  My name is Darcel from OSNC.
  I understand that you have an appointment with Dr Wheeless for March 29th? is that correct?
  I understand that you made a partial payment at the last visit, will you be able to make an additional payment before the next visit?
  Would it be OK if we went through some screening questions, which are design to improve the quality of your visit?
  Thank you.  Basically we are going through a review of all of the questions and issues thay you need addressed by Dr Wheeless.


   1) How old are you and what is your current occupation (job, homemaker, retired, disabled, or unemployed).
          - if retired/unemployed what was prior job, and if disability for what.
          - example:  Ms Jane Doe is a 55 year old retired teacher who {presents with/being followed for}...................
                             Mr. John Doe is a 45 year old disabled male (old back injury, and diabetes) who {presents with/being followed
                                        for}................
   2) What brings you in to see us?
          - list each
          - example: 1) neck pain which radiates down the left arm, 2) hand numbness, 3) bilateral knee pain.
          - therefore: Ms Jane Doe is a 55 year old retired teacher who presents with 1) neck pain which radiates down the left arm,
                             2) hand numbness, 3) bilateral knee pain.

   3) How long have you had these symptoms? give date or length of time.
          - was there an accident?
          - was there an injury at work
          - date of injury
          - ex: The neck has caused {symtpoms/pain/problems} "ever since the car accident on ........" or "for the past 5-6 months."
          - ex: The hands have been numb for 2 months.
          - ex: The knees have been causing pain for the past 10 years.

   4) How severe are each of these conditions?
          - list severity of each, but the description needs to be added to the end of the prior sentence from # 3)
          - ex: neck is very severe all the time, hands are moderately severe at night, and knee pain is severe during the day.
          - therefore ex:
                 Ms Jane Doe is a 55 year old retired teacher who presents with 1) neck pain which radiates down the left arm,
                 2) hand numbness, 3) bilateral knee pain. 
The neck has caused pain ever since the car accident on Jan 1, 2014 and
                 causes very severe pain.  The 
hands have been numb for 2 months and cause moderately severe pain.  The knees
                 have been causing pain for the past 10 years and the knee pain is severe.

   How Frequent are these symptoms?  (day and/or night)
          - how often does it cause pain or problems
          - ex: neck hurts all of the time, hands at night only, and knees during the day.
          - so each of these lines gets added to the end of the appropriate sentence.

                 Ms Jane Doe is a 55 year old retired teacher who presents with 1) neck pain which radiates down the left arm,
                 2) hand numbness, 3) bilateral knee pain. 
The neck has caused pain ever since the car accident on Jan 1, 2014 and
                 causes very severe pain all of the time.  The 
hands have been numb for 2 months and cause moderately severe pain
                 at night. 
The knees have been causing pain for the past 10 years and the knee pain is severe only during the day.

   What have you done to address these symptoms (PT, injections, medications, braces, recent surgery)
          - what makes it better
          - what makes it worse
          - ex: the patient has tried percocet from the ER and this helps but the neck brace makes it worse.
          - ex: nothing helps the hands
          - ex: Dr Yenni gave an injection into the left knee last year and this gave good relief for 6 months.  Motrin and Percocet also
                  help.
          - again add them to the end of the paragraph.  Try saying, "he/she notes that the percocet from the ER help.....

                 Ms Jane Doe is a 55 year old retired teacher who presents with 1) neck pain which radiates down the left arm,
                 2) hand numbness, 3) bilateral knee pain. The neck has caused pain ever since the car accident on Jan 1, 2014 and
                 causes very severe pain all of the time.
  She notes that percocet from the ER and this helps but the neck brace makes
                 it worse. 
The 
hands have been numb for 2 months and cause moderately severe pain at night.  She notes that
                 nothing helps the hands.  
The knees have been causing pain for the past 10 years and the knee pain is severe only
                 during the day.
  She notes that Dr Yenni gave an injection into the left knee last year and this gave good relief for 6
                 months.  Motrin and Percocet also help the knee pain.


    Prior Surgery or other intervention.
              - the patient has had a cholecystectomy 2004, hernia repair 1990, right knee scope in 1995, and back surgery in 1989.
                        - the non pertinent (non orthopaedic) cases can be parked into the past medication section at the bottom.
              - always ask about heart attacks, sents, strokes, and any vascular surgery including stents.
                        - the patient had a mini stroke in 2005, and had a cardiac stent in 2009, and a right leg vascular sent in 2010.
              - take only the pertinent surgery and park it at the end of the appropriate sentence.
                        - in this example, the right leg vascular stent is parked at the end of the knee paragraph, and the entire sentence is
                          parked at the very end of the paragraph.
              - may say: "of note, the patient has had a right knee scope in 1995.

                Ms Jane Doe is a 55 year old retired teacher who presents with 1) neck pain which radiates down the left arm,
                 2) hand numbness, 3) bilateral knee pain. 
The neck has caused pain ever since the car accident on Jan 1, 2014 and
                 causes very severe pain all of the time. 
She notes that percocet from the ER and this helps but the neck brace makes
                 it worse. 
The 
hands have been numb for 2 months and cause moderately severe pain at night.  She notes that
                 nothing helps the hands.  
The knees have been causing pain for the past 10 years and the knee pain is severe only
                 during the day.
  She notes that Dr Yenni gave an injection into the left knee last year and this gave good relief for 6
                 months. 
Motrin and Percocet also help the knee pain.  Of note, the patient has had a right knee scope in 1995.  Of
                 note she has had a right leg vascular stent in 2010.



   What imaging studies have you had?
                 - CT scan of neck in ER, and radiographs of knee in ER.
                 - again add to the end of the appropriate sentence.
                 - "a CT scan of the neck was performed in the ER at the time of the accident."

                 Ms Jane Doe is a 55 year old retired teacher who presents with 1) neck pain which radiates down the left arm,
                 2) hand numbness, 3) bilateral knee pain. 
The neck has caused pain ever since the car accident on Jan 1, 2014 and
                 causes very severe pain all of the time. 
She notes that percocet from the ER and this helps but the neck brace makes
                 it worse. 
A CT scan of the neck was performed in the ER at the time of the accident.  The hands have been numb
                 for 2 months and cause moderately severe pain at night.  She notes that nothing helps the hands.  
The knees have
                 been causing pain for the past 10 years and the knee pain is severe only during the day.
  She notes that Dr Yenni
                 gave an injection into the left knee last year and this gave good relief for 6 months.  Motrin and Percocet also help
                 the knee pain. 
Of note, the patient has had a right knee scope in 1995.  Of note she has had a right leg vascular stent
                 in 2010.
An xray of the knees was taken in the ER


   What orthopaedic medications or pain medications are you currently taking / any bad reactions?
            - need to ask about narcotics, ultram, antiinflammatories like motrin, and as well as neurotin, lyrica, and cymbalta.
            - if already mentioned, then move on.
            - reactions and side effects.
                  - do ask if there is any problem with the motrin.
                  - neurontin causes bad dreams.
                  - always ask about sedation with narcotics, and any problems with driving. / compliance with medication.
            - example: 800 mg Mortrin causes stomach upset, but 400 mg taken 3 times daily with food is tolerated.
            - example: She denies any sedation with the Percocet, has no problems with driving, and is taking the medication as directed.
            - "she notes that"
            - Any allergies.
                     - iodine, and sulfa
            - is the patient taking any blood thinners?
                     - The patient is taking Plavix.

                 Ms Jane Doe is a 55 year old retired teacher who presents with 1) neck pain which radiates down the left arm,
                 2) hand numbness, 3) bilateral knee pain. 
The neck has caused pain ever since the car accident on Jan 1, 2014 and
                 causes very severe pain all of the time. 
She notes that percocet from the ER and this helps but the neck brace makes
                 it worse. 
A CT scan of the neck was performed in the ER at the time of the accident.  The hands have been numb
                 for 2 months and cause moderately severe pain at night.  She notes that nothing helps the hands.  
The knees have
                 been causing pain for the past 10 years and the knee pain is severe only during the day.
  She notes that Dr Yenni
                 gave an injection into the left knee last year and this gave good relief for 6 months.  Motrin and Percocet also help
                 the knee pain. 
Of note, the patient has had a right knee scope in 1995.  An xray of the knees was taken in the ER
                 Of note she has had a right leg vascular stent in 2010.  She notes that 800 mg Mortrin causes stomach upset, but 400
                 mg taken 3 times daily with food is well tolerated.
  Neurontin causes bad dreams. She denies any sedation with the
                 Percocet, has no problems with driving, and is taking the medication as directed.
  She is allergic to iodine and sulfa.
                 The patient is taking Plavix.  Of note, she has had a mini stroke in 2005, and had a cardiac stent in 2009, and a right
                 leg vascular sent in 2010.


     Cardiac/Vascular Issues:
              - always ask about heart attacks, sents, strokes, and any vascular surgery including stents.
                        - the patient had a mini stroke in 2005, and had a cardiac stent in 2009, and a right leg vascular sent in 2010.
              - take only the pertinent surgery and park it at the end of the appropriate sentence.
                        - in this example, the right leg vascular stent is parked at the end of the knee paragraph, and the entire sentence is
                          parked at the very end of the paragraph.
  Clean it up:
       - break up the paragraph into parts and label the headings.

           Chief Complaint:
                 Ms Jane Doe is a 55 year old retired teacher who presents with 1) neck pain which radiates down the left arm,
                 2) hand numbness, 3) bilateral knee pain.
           Neck:
                
The neck has caused pain ever since the car accident on Jan 1, 2014 and causes very severe pain all of the time.
                
She notes that percocet from the ER and this helps but the neck brace makes it worse.
               
A CT scan of the neck was performed in the ER at the time of the accident.
           Hands:
                
The 
hands have been numb for 2 months and cause moderately severe pain at night.  She notes that nothing helps
                 the hands.
           Knees:
                
The knees have been causing pain for the past 10 years and the knee pain is severe only during the day.
               
  She notes that Dr Yenni  gave an injection into the left knee last year and this gave good relief for 6 months.
                 Motrin and Percocet also help the knee pain.
                
Of note, the patient has had a right knee scope in 1995.  An xray of the knees was
                 taken in the ER
Of note she has had a right leg vascular stent in 2010.
           Orthopaedic Medications:
                 She notes that 800 mg Mortrin causes stomach upset, but 400 mg taken 3 times daily with food is well tolerated.
 
                 Neurontin causes bad dreams. The patient is taking Plavix. 
                She denies any sedation with the Percocet, has no problems with driving, and is taking the medication as directed.
           Cardiac/Vascular Issues:
                 Of note, she has had a mini stroke in 2005, and had a cardiac stent in 2009, and a right leg vascular sent in 2010.

  Review of Systems:
          Any nausea, vomting, fever, chills, chest pain, abdominal pain, mood swings, loss of balance, loss of coordination, hematuria,
          and diarrhea.

               ..... The patient states that there is diarrhea, but no nausea, fever, chills, chest pain, abdominal pain, mood swings, ect.....

  Past medical history:
               ...... the patient notes that she has a history of diabetes, and HTN, and a Mini stroke in 2005.

  Review of Narcotic use Web site:
         - look up website and report it.
         - note any urine drug screens.
                  - do not ask the patient if there has been a urine drug screen unless there has been a reason or if narcotics have been taken
                    for more than 6 months.
         - this information can be parked into the end of the orthopaedic medication section.

Final Product:

           Chief Complaint:

                 Ms Jane Doe is a 55 year old retired teacher who presents with 1) neck pain which radiates down the left arm,
                 2) hand numbness, 3) bilateral knee pain.
           Neck:
                
The neck has caused pain ever since the car accident on Jan 1, 2014 and causes very severe pain all of the time.
                
She notes that percocet from the ER and this helps but the neck brace makes it worse.
                
A CT scan of the neck was performed in the ER at the time of the accident.
           Hands:
                
The 
hands have been numb for 2 months and cause moderately severe pain at night.  She notes that nothing helps
                 the hands.
           Knees:
                
The knees have been causing pain for the past 10 years and the knee pain is severe only during the day.
               
  She notes that Dr Yenni  gave an injection into the left knee last year and this gave good relief for 6 months.
                 Motrin and Percocet also help the knee pain. 
Of note, the patient has had a right knee scope in 1995.
                 An xray of the knees was taken in the ER
Of note she has had a right leg vascular stent in 2010.
           Orthopaedic Medications:
                 She notes that 800 mg Mortrin causes stomach upset, but 400 mg taken 3 times daily with food is well tolerated.
 
                 Neurontin causes bad dreams. The patient is taking Plavix. 
                 She denies any sedation with Percocet, has no problems with driving, and is taking the medication as directed.
                 Review of NC Narcotic use Web site:
                         The patient has only received one recent prescription for 60 percocet tablets from Wake Med on Jan 1, 2014.
                         No indication for urine drug screen.

           Cardiac/Vascular Issues:

                 Of note, she has had a mini stroke in 2005, and had a cardiac stent in 2009, and a right leg vascular sent in 2010.

           ROS:
                  The patient states that there is diarrhea, but no nausea, fever, chills, chest pain, abdominal pain, mood swings, loss
                  of balance, loss of coordination, hematuria, and diarrhea.


           Past medical history:

                  The patient notes that she has a history of diabetes, and HTN, and a Mini stroke in 2005.  The patient has had a
                  cholecystectomy 2004, hernia repair 1990, right knee scope in 1995, and back surgery in 1989.




The above information is imported into a face sheet;
         there needs to be a line for a provider signature.
         if signed then the entire paragraph is imported as the History for the visit, and the exam and plan are done later.
         the provider will hand write notes on the face sheet, and so it still needs to be scanned.
         If there are changes that are required to the face sheet, I will just dictate the changes, such as, please change the Cardiac/Vascular
         section, "from a mini stroke in 2005 to a major stroke in 2005."

         Each subsequent visit, the phone reviewer will again call the patient and update the paragraph.
         They should have a download of the typed text.
         If the neck is no longer a problem, then it can be deleted.
         If we got an MRI of the right knee, and a right knee steroid shot, it would say the following with an updated history while still having the orginal history.           (we still need to describe severity and frequency.)  We want to ask if the shot helped, and whether the patient wants another shot.  We need to check the pharmacy web site if needed or say, has not been checked from the original visit.
Finally, the phone reviewer needs to look at the last plan from the last note if there was a previous visit.
if the plan was to get authorization for Euffluxa, then we need to know the status if possible or just say we will know only on the day
of the visit.

          Knees:
            updated history:
                 At the last visit the patient has had a steroid shot, which has given 50% pain relief.  She notes that she wants another
                 steroid shot today.
                 The knee pain is now moderate during the day.  Motrin and Percocet continue to help.
                 Since the last visit the patient has had an MRI of the knee.  Report is attached.

                 An Eufflex authorization was started but is still pending as of March 27th.

            original history:
                
The knees have been causing pain for the past 10 years and the knee pain is severe only during the day.
               
  She notes that Dr Yenni  gave an injection into the left knee last year and this gave good relief for 6 months.
                 Motrin and Percocet also help the knee pain. 
Of note, the patient has had a right knee scope in 1995.
                 An xray of the knees was taken in the ER
Of note she has had a right leg vascular stent in 2010.

           Orthopaedic Medications:
                 She notes that 800 mg Mortrin causes stomach upset, but 400 mg taken 3 times daily with food is well tolerated.
 
                 Neurontin causes bad dreams. The patient is taking Plavix. 
                 She denies any sedation with Percocet, has no problems with driving, and is taking the medication as directed.
                 Review of NC Narcotic use Web site:
                         The patient has only received one recent prescription for 60 percocet tablets from Wake Med on Jan 1, 2014.
                         No indication for urine drug screen.


Parting comments:
In this case, it would be nice for the steroid shot to be in the room, and it would be nice to be mindful of the narcotic web site so that we do not have to check this during the day, if possible.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, March 31, 2014 10:20 am