Medical reference Medical guideline Patient factors Provider factors Environment/system factors. Conduct medical encounter

Transcription

1 Used At: Author: Ken Funk, Mylie Tong, James Bau Date: 6/23/2011 Time: 21:35:03 Medical guideline Patient factors factors Environment/system factors New/returning patient Patient medical records Existing patient-provider relationship Existing diagnosis(es) Existing treatment plan Previously requested test results 's initial understanding of patient's problems Patient perceived problems Conduct medical encounter A0 Healing patient Updated medical records Follow-up schedule Test requisition 's updated understanding of patient's problem after the encounter Patient's enhanced understanding of problems Ongoing patient-provider relationship Final diagnosis(es) Final treatment plan Node: C1 Title: Conduct Medical Encounter Number: Pg 17 D-17

2 Used At: Author: Ken Funk,Mylie Tong C3 C4 C5 Patient factors factors Environment/system factors Date: 12/31/2010 Time: 20:50:50 C2 C1 Medical guideline I7 I8 Existing patient-provider relationship 's initial understanding of patient's problems Patient perceived problems Establish & maintain patient-provider relationship Established shared goals 's updated understanding of patient-provider relationship Ongoing patient-provider relationship 's updated understanding of patient's problem after the encounter O7 O5 A1 I4 I5 I6 Existing diagnosis(es) Existing treatment plan Previously requested test results Patient medical records New/returning patient Patient self-knowledge Collect and integrate clinical information A2 Updated patient self-knowledge Examination results 's updated understanding of integrated patient information Healing patient Test requisition Updated medical records O4 Diagnose condition 's understanding of final diagnosis Final diagnosis(es) O8 A3 Discussion about the final diagnosis Patient in treatment Treat patient Final treatment plan O9 's understanding after implementing the treatment. A4 Discussion about treatment plan 's understanding with discussed follow-up plan Plan follow-up A5 Discussion of follow-up plan Follow-up schedule Patient's enhanced understanding of problems O6 M1 M3 M2 M5 M4 Node: C2 Title: A0: Conduct medical encounter Number: Pg 18 D-18

3 Date: 12/31/2010 Time: 21:34:16 C3 C1 C2 Environment/system factors Patient factors factors Existing patient-provider relationship Communication channel 's initial understanding of patient's problems Patient perceived problems Open communication channel A11 Identify patient's background 's understanding of patient's background Ongoing patient-provider relationship A12 's updated understanding of patient-provider relationship I6 I5 Discussion about the final diagnosis Discussion about treatment plan Establish shared goals 's understanding of shared goals Established shared goals I4 Discussion of follow-up plan A13 Establish mutual trust 's understanding by mutual trust Established mutual trust A14 's understanding of beneficence Establish beneficence Established beneficence A15 M1 M2 Node: C3 Title: A1: Establish & maintain patient-provider relationship Number: Pg 19 D-19

4 C2 C6 Established shared goals Date: 1/2/2011 Time: 06:57:30 I6 I5 Patient self-knowledge 's updated understanding of patient-provider relationship Characterize symptoms of Patient medical records urgent problems 's perceived urgency Characterized symptom 's understanding of characterized symptoms Updated patient self-knowledge A21 Updated medical history with characterized symptoms Updated medical records I4 Existing diagnosis(es) Existing treatment plan Previously requested test results Electronic medical record system Review comprehensive medical history A22 understanding of reviewed medical history Reviewed medical history Conduct review of organ systems A23 Review of organ systems 's understanding of review of organ systems. Updated medical history with review of organ system Test requisition Conduct physical examination 's understanding of physical exam results Updated medical records with examination results Examination results O4 A24 Assess treatment plan effectiveness 's understanding of treatment plan effectivness Assessment of existing treatment A25 Integrate patient information O6 's updated understanding of integrat O5 A26 M5 M4 M3 Node: C4 Title: A2: Collect and integrate clinical information Number: Pg 20 D-20

5 C4 C2 C1 C3 C5 's perceived urgency Reviewed medical history Review of organ systems Characterized symptom Test requisition Date: 1/2/2011 Time: 06:57:07 Updated medical history with review of organ system Cardio-pulmonary status 's understanding of review of organ systems. Check cardio-pulmonary status 's understanding of vital sign conditions Examination results 's understanding of physical exam results A241 Updated medical records with cardio-pulmonary status Updated medical records with examination results Evaluated abdominal area results Evaluate gastrointestinal status 's understanding of gastrointestinal status results Updated medical records with gastrointestinal status A242 Examine skin and body condition Skin and body condition 's understanding of skin and body condition Updated medical results with skin and body exam A243 Examine head and neck Head and neck condition 's understanding of head and neck condition Updated medical records with head and neck condition A244 Sexual organs check results Examine genitourinary system 's understanding of genitourinary exam results Updated medical records with sexual organs condition A245 Conduct neurologic and mental status examination A246 Neurologic and mental status results Updated medical records with neurologic and mental condition 's understanding of neurologic and mental status M3 M1 M2 Node: C9 Title: A24: Conduct physical examination Number: Pg 21 D-21

6 C1 C3 C2 C4 C6 C5 's perceived urgency Review of organ systems Reviewed medical history Characterized symptom Test requisition Date: 1/2/2011 Time: 06:58:29 Updated medical history with review of organ system Check vital signs 's understanding of review of organ systems. Vital signs results Updated medical records with vital signs results Cardio-pulmonary status Updated medical records with cardio-pulmonary status A2411 's understanding of vital signs results 's understanding of vital sign conditions Assess pulmonary exam A2412 Pulmonary exam results 's understanding of pulmonary exam results Updated medical records with pulmonary exam results Stethoscope Cardiac function condition Check cardiac function 's understanding of cardiac function condition A2413 Updated medical records with cardiac function condition Stethoscope Sphygmomanometer (BP Cuff) Medical light device Check Pulmonary Condition Pulmonary condition 's understanding of pulmonary condition Updated medical records with pulmonary results A2414 Stethoscope Updated medical records with oxygenation percentage Assess oxygenation percentage 's understanding of oxygenation percentage Oxygenation percentage Stethoscope A2415 M2 M3 M1 Node: C11 Title: A241: Check cardio-pulmonary status Number: Pg 22 D-22

7 C6 C5 C4 C3 C2 C1 Medical guideline Environment/system factors factors Patient factors Ongoing patient-provider relationship Test requisition Characterized symptom Reviewed medical history Review of organ systems 's perceived urgency Date: 1/2/2011 Time: 06:58:27 Updated medical history with review of organ system 's understanding of temperature results 's understanding of vital signs results 's understanding of review of organ systems. Check temperature Temperature results Vital signs results Updated medical records with temperature condition Updated medical records with vital signs results A24111 Temperature Device 's understanding of respiration results Check respiration Respiration results Updated medical records with respiration condition A24112 Time display device Stethoscope 's understanding of pulse results Check pulse Pulse results Updated medical records with pulse condition A24113 Time display device Stethoscope Updated medical records with blood pressure condition Check blood pressure 's understanding of blood pressure results Blood pressure results Sphygmomanometer (BP Cuff) A24114 M2 M3 M4 M5 M1 Node: C18 Title: A2411: Check vital signs Number: Pg 23 D-23

8 C2 C1 C4 C3 C6 C5 C7 's perceived urgency Cardio-pulmonary status Review of organ systems Reviewed medical history Characterized symptom Test requisition Date: 1/2/2011 Time: 06:57:52 Updated medical records with cardio-pulmonary status 's understanding of vital sign conditions Perform inspection 's understanding of inspection results Normal or abnormal condition of abdominal area 's understanding of gastrointestinal status results Evaluated abdominal area results A2421 Updated medical records with inspection results Updated medical records with gastrointestinal status Palpate patient's abdomen A2422 's understanding of palpation results Palpation results Updated medical records with palpation results Auscultation sounds Perform auscultation 's understanding of auscultation results Updated medical records with auscultation results Stethoscope A2423 Percussion sounds responses Perform percussion 's understanding of percussion resutls Updated medical records with percussion results Stethoscope A2424 Rectal exam results Perform rectal exam Updated medical records with rectal exam results 's understanding of rectal exam results A2425 Special tests results Perform special tests 's understanding special tests results Updated medical records with special tests results A2426 Electronic medical history system M3 M1 M2 Node: C12 Title: A242: Evaluate gastrointestinal status Number: Pg 24 D-24

9 C2 C1 C4 C3 C5 C7 C6 's perceived urgency Cardio-pulmonary status Review of organ systems Reviewed medical history Characterized symptom Test requisition Date: 1/2/2011 Time: 06:57:53 Updated medical records with gastrointestinal status Skin examination results 's understanding of vital sign conditions 's understanding of gastrointestinal status results Perform skin examination 's understanding of skin exam results Skin and body condition 's understanding of skin and body condition A2431 Updated medical records with skin exam results Updated medical results with skin and body exam Camera Back and extremity examination results Perform musculatory system exam 's understanding of musculatory exam results Updated medical records with musculatory exam results Camera A2432 Breast examination results Perform breast exam 's understanding of breast exam results Updated medical records with breast exam results A2433 Lymphatic examination results Perform lymphatic exam Updated medical records with lymphatic exam results 's understanding of lymphatic exam results A2434 Electronic medical history system M1 M3 M2 Node: C10 Title: A243: Examine skin and body condition Number: Pg 25 D-25

10 C2 C1 C4 C3 C6 C5 C7 Date: 1/2/2011 Time: 06:57:54 's perceived urgency Cardio-pulmonary status Review of organ systems Reviewed medical history Characterized symptom Test requisition Updated medical results with skin and body exam Head condition 's understanding of vital sign conditions 's understanding of skin and body condition Perform eye exam 's understanding of head exam results Head and neck condition 's understanding of head and neck condition Updated medical records with eye condition Updated medical records with head and neck condition A2441 Ophthalmoscope Medical Gloves Perform ear exam Ear condition 's understanding of ear exam results Updated medical records with ear condition A2442 Nose condition Medical Gloves Otoscope Cotton Tipped Applicators Perform nose exam 's understanding of nose exam results Updated medical records with nose condition A2443 Medical Gloves Throat condition Cotton Tipped Applicators Perform throat exam 's understanding of throat exam results Updated medical records with throat condition A2444 Medical Gloves Neck condition Tongue Blades Medical light Perform neck exam 's understanding of neck exam results Updated medical records with neck condition A2445 Medical Gloves Special test results Perform special exam Updated medical records with special test results 's understanding of special exam results A2446 Electronic medical history system M3 M1 M2 Otoscope Medical Gloves Node: C13 Title: A244: Examine head and neck Number: Pg 26 D-26

11 C7 Date: 12/31/2010 Time: 20:50:38 I4 Examination results 's updated understanding of integrated patient information Patient medical records Evaluate integrated patient information A31 Evaluation of integrated patient information Evaluate shared goal and define overall diagnosis task A32 Evaluation of shared goal and overall task Generate diagnostic Updated medical records with Hypotheses Updated medical records A33 Refute unlikely A34 Updated medical records after refuting Diagnoses after refuting alternatives 's understanding of refuted diagnoses Confirm most likely diagnosis A35 Updated medical records after confirm final diagnosis Confirmed diagnosis 's understanding of final diagnosis O4 Discuss and explain diagnosis with patient A36 Updated medical records with final diagnosis. Final diagnosis(es) Discussion about the final diagnosis O5 M2 M1 M3 M4 Node: C5 Title: A3: Diagnose condition Number: Pg 27 D-27

12 I4 C1 Medical guideline Ongoing patient-provider relationship Date: 12/28/2010 Time: 17:46:59 Environment/system Patient factors factors factors Established shared goals Patient medical records Review patient medical history 's updated understanding of integrated patient information Review of patient medical records 's understanding of review of patient's medical records A311 Physical findings assessment Analyze physical findings 's understanding of physical findings assessment Examination results A312 Decision making aid system Assess patient's symptoms and test results with provider's own medical knowledge Assessment of patient's condition from provider's own knowledge 's understanding of the assessment A313 Probe more relevant medical information from medical reference A314 's understanding with more relevant medical information More relevant medical information Evaluation of integrated patient information Generate evaluation Decision making aid system A315 M4 M3 M1 M2 Node: C15 Title: A31: Evaluate integrated patient information Number: Pg 28 D-28

13 Ongoing patient-provider relationship Date: 1/1/2011 Time: 19:15:14 C1 Evaluation of shared goal and overall task Evaluation of integrated patient information Review previous evaluation Evaluation relevant to diagnoses A331 Generate from provider's own medical knowledge Working diagnosis based on provider's own medical knowledge Information needed beyond provider's own knowledge A332 Generate from medical reference A333 Working diagnosis based on medical reference Information needed beyond medical reference Identify additional information needed for diagnosis A334 Working diagnosis after collecting more medical evidence I4 Patient medical records Form diagnostic Hypotheses Updated medical records with A335 Decision making aid system M1 M2 M3 M4 Node: C16 Title: A33: Generate diagnostic Number: Pg 29 D-29

14 C1 C2 Evaluation of shared goal and overall task Evaluation of integrated patient information Date: 12/28/2010 Time: 17:46:59 C3 Hypotheses Identify expected outcomes of diagnostic Expected condition of diagnosis A341 Electronic medical record system Compare diagnostic ' outcomes with patient's condition A342 Matched Mismatched Refute from provider's own medical knowledge Information needed beyond provide's own medical knowledge Working diagnosis based on provider's own medical knowledge A343 Decision making aid system Refute with medical reference A344 Working diagnosis based on medical reference Information needed beyond medical reference Identify additional information needed for refuting diagnoses A345 Working diagnosis after collecting more medical evidence Updated medical records with Diagnoses after refuting alternatives Refute wrong 's understanding of refuted diagnoses Updated medical records after refuting A346 Decision making aid system O4 M1 M2 M3 M4 Node: C17 Title: A34: Refute unlikely Number: Pg 30 D-30

15 C1 C2 Evaluation of shared goal and overall task Evaluation of integrated patient information Date: 12/28/2010 Time: 17:46:59 C3 Diagnoses after refuting alternatives 's understanding of refuted diagnoses Identify the expected outcomes of the remaining diagnosis A351 The outcomes of remaining I4 Consider other factors related to patient condition A352 Working diagnoses after considering all the factors Assess probability of remaining based on provider's own knowledge A353 Information needed beyond provide's own medical knowledge Working diagnosis with probability based on provider's own medical knowledge Assess probability of remaining diagnosis based on medical reference A354 Information needed beyond medical reference Working diagnosis with probablity based on medical reference Identify additional information needed for confirming A355 Working diagnosis after collecting more medical evidence Confirmed diagnosis O4 Finalize Updated medical records after confirm fina diagnosis Updated medical records after refuting 's understanding of final diagnosis A356 M4 M3 M2 M1 Node: C19 Title: A35: Confirm most likely diagnosis Number: Pg 31 D-31

16 C4 C9 C8 C7 C6 C5 C3 C2 C1 Established shared goals Medical guideline Environment/system factors factors Patient factors Ongoing patient-provider relationship Final diagnosis(es) Date: 11/24/2010 Time: 11:02:02 New/returning patient 's understanding of possible treatment plans Patient medical records Create possible treatment plan Possible treatment plans 's understanding of final diagnosis A41 Review contraindication 's understanding of treatment plan after reviewing contraindications Updated treatment plan A42 Discuss treatment plan with patient Discussed treatment plan 's understanding with preliminary treatment plan Discussion about treatment plan O5 A43 Decision making aid system Final treatment plan Generate final treatment plan Updated medical records with treatment plan Updated medical records 's understanding of current treatment evaluation A44 Decision making aid system Updated medical records with results of initial treatment. Implement initial treatment Patient in treatment A45 's understanding after implementing O4 M1 M3 M4 M2 M5 Node: C6 Title: A4: Treat patient Number: Pg 32 D-32

17 C9 C8 C7 C6 C5 C4 C3 C2 C1 Final diagnosis(es) Ongoing patient-provider relationship Patient factors factors Environment/system factors Medical guideline Established shared goals Date: 12/28/2010 Time: 15:53:40 New/returning patient 's understanding with assessed diagnoses 's understanding of final diagnosis Review diagnosis Assessed diagnoses Patient medical records Decision making aid system A411 Evaluate patient's comprehensive information 's understanding with patient's comprehensive information Reviewed comprehensive patient's records A412 Research latest treatment options and relevant medical information 's understanding with relevant medical information Relevant medical information of latest treatment options A413 Form possible treatment 's understanding of possible treatment plans Possible treatment plans Decision making aid system A414 M1 M2 M3 Node: C14 Title: A41: Create possible treatment plan Number: Pg 33 D-33

18 Date: 12/28/2010 Time: 18:46:06 C6 C3 C1 C4 C7 C5 C2 factors Ongoing patient-provider relationship Final treatment plan Established shared goals Environment/system factors Patient factors Patient medical records Review patient's information 's understanding after implementing the treatment. 's understanding with reviewed information Reviewed patient's information A51 Establish follow-up plan A52 's understanding with follow-up plan Follow-up plan Updated medical records Discuss follow-up plan with patient A53 Follow-up schedule 's understanding with discussed Discussion of follow-up plan O5 Patient's enhanced understanding of pro O4 M2 M1 M3 M4 Node: C7 Title: A5: Plan follow-up Number: Pg 34 D-34