Physical Exam Template Nurse Practitioner Form: Fill & Download for Free

So many things are getting lost.But, I would have to say, right now, that the skill I grieve for most is the art of storytelling.Many people don't realize this, but a big part of a doctor’s onus is to convey the essence of the patient, their history, the story of their illness, including what they think is the problem, and what they have done to treat it.These narratives are called ‘History and Physicals’ or H&Ps. They are the backbone of the patient’s care. Every single physician, nurse, and other practitioner would consult this document to acquaint themselves with the patient’s history and baseline physical exam. They would run something like:“Mrs. Smith is 45 year old married woman who presents today with a complaint of a headache for three days. She denies any nausea, vomiting or trauma to the head. She states she has a history of migraine headaches, which started in her early teens.”It would then proceed to address the patient’s past medical history, family history and then the physical exam. They would always be set up in SOAP format, and would end with the assessment and plan.These would be transcribed from a doctor who would dictate this information typically, right after seeing the patient. The transcription would generally take less than an hour, and voila, it appears in their medical record.Now, thanks to the bumbled efforts with EHR and the oncoming generation’s dislike of speaking into a phone, the records look like:Male ( ) Female (X ) presents with chest pain ( ) nausea ( )vomiting ( ) headache ( X). And so on.Doctors are now set up with their own templates in which they click boxes. Not just H&Ps, but operative notes and progress notes. They also pull in every lab, vital sign, radiology result, medication orders etc. from the last 36 hours so they have become very much like spam notes.Reading them is the visual equivalent of army crawling through barbed wire.An attending that I work with and I recently had this discussion about these templates and he had this to say:“The residents don't even use the phone to dictate anymore. I suggested to a first year that she just dictate the H&P while they were getting a patient ready for surgery. She was flabbergasted, she had never dictated and said that if she couldn't just text something it threw her off.”Electronic health records-welcome to the new boss.

The incorporation of computer applications into the healthcare system has generally made it profoundly more expensive and vastly less efficient. I will address the reasons for both of these problems. The opinion of anyone not directly involved in the practice of medicine during this trial and error process of adopting "Information Technology" is simply uninformed speculation. Magical thinking abounds. Unfortunately, this includes large portions of our government bureaucracy.Let me emphasize that I have great confidence that IT will one day improve the efficiency of healthcare delivery, but during this transition period (which will last at least one to two decades) it is having the opposite effect.My undergraduate degree is in Engineering Physics. I am comfortable with concrete "hard science" methods of thinking (like most computer scientists I know), but there are a plethora of reasons why this is of limited use when taking care of patients in the real world. Suffice it to say, I know why this question seems reasonable to the person who asked it - I had a similar view of Medicine before I entered medical school.How has the introduction of IT to the practice of medicine affected it so far? The government has imposed regulations requiring medical information to be put into a database. We used to write (or dictate) a half page note which would summarize the patient's status that any other physician could read and immediately understand what was going on with that patient. (An initial evaluation would require a few pages, but obviously most patient care takes place after the initial visit.) The government has a simple means of enforcing this requirement (which all insurance companies have in turn adopted) - they don't pay you if you don't do it. Clinic visits are billed based on "level of service". There are precise definitions of these levels based on the quantity of information in various categories - History of present illness (HPI), past medical history, medications, allergies, family history, social history and a one page (at least) summary of "Review of Systems" which consists of symptoms from all major organ systems - cardiac, pulmonary, neuro, gi, etc - 11 or more all together, followed by a physical exam (examining at least eleven organ systems), laboratory evaluation, imaging studies, assessment (covering all identified problems), medical decision making - the reasoning (precisely spelled out) behind how we might address each of these problems, and finally a plan of action (for each problem).Computer programs to the rescue - Many programs are now available that will provide a template for the clinic note. The doctor then places the pertinent information into this template (in bold type, so another doctor can read it and actually know what's important) and the rest is printed as "normal" findings. The bold type represents what used to be in the half page note and the other 8 - 10 pages contains the information necessary to bill the top level for that clinic visit. For example, we used to get paid $50 for seeing the patient and doing a half page note - now we can get $150 for seeing the same patient and putting the information into the program. Why not bill the highest level for each visit? - we didn't make the rules, we're just following them.Not only can we bill three times as much as we used to, in order to make the same amount of money, we must do it - because it takes 2 - 3 times as long to input the info into the computer than it did to just dictate what was important.Every patient must have a 3 - 6 digit alphanumeric code for each of (thousands) of diagnoses. Every procedure performed has a five digit code.On the average, surveyed physicians say they can see about half as many patients as they used to - because the process is now so inefficient. Patients complain that the doctor interacts less with them because he spends more than half the visit typing on the damned computer. The human interaction between doctors and their patients - the empathy - is lost - because of the government's intrusion - since they now require collection of information in a digital format - so more bureaucrats can analyze the data for God knows what purpose.There has long been a shortage of doctors which is now twice as bad because each doctor can see only half as many patients. The solution so far has been to use "physician extenders" like Nurse Practitioners and Physician's Assistants - people with less than half as much education who, of course, work less efficiently than do doctors - ordering more of the wrong (expensive) tests - prescribing the wrong treatment leading to complications, etc. (Most of the time they are good at taking care of common problems, but may miss more complex things due to a lack of education and experience.)So "Why haven't medicine and computer science made more progress in automating clinical diagnosis?"The process of data entry is horribly inefficient. Just based on the examples above, you can see how this has adversely affected the practice of medicine so far. If one tried to enter all of the information necessary to make a diagnosis, it would take much longer.The results are only as good as the information provided to the program. There are many pertinent aspects of the HPI that are only collected if the person asking the patient the questions knows what questions to ask. Vague symptoms need to be specifically described - details need to be drawn out and it takes an experienced interviewer (doctor) to get the relevant information from the patient. Only then can the computer be given accurate information. Similarly, the physical examination needs to be carried out by someone who has done this a thousand or more times (which is why medical students and residents practice this with supervision for a minimum of six years (after training in the basic sciences) before getting to actually practice medicine). There are subtle nuances, often difficult to describe, as to how everything looks, feels and sounds. Perhaps these could ultimately be "learned" by an AI program - a nurse could poke a camera into every orifice (as well as photographing every external contour of the patient) - and some method could be developed for inputting tactile information to the computer (this sensory apparatus would have to "feel" the patient from head to toe) and putting a microphone against the skin over the heart, lungs and blood vessels.After entering the initial information from the history and physical examination, the program might give you a list of additional information it needs in the form of laboratory values and imaging studies. Inputting lab values is easy, but finding a way to enter all the nuances of imaging findings will be difficult. Usually imaging findings can't be described in a single sentence, but rather as a list of possibilities - "a picture is worth a thousand words" - and it takes a long time to describe something in a thousand words - much less doing so in a format that an AI program can understand. A program will have to be developed that can actually "look" at the imaging itself and learn to interpret it.After multiple iterations, a biopsy may be needed, and again, an AI program would need to be developed to interpret every nuance of cellular structure and organization - and in turn recommend special staining of the slides - immuno-studies, and imitate the cry of most pathologists: "We need more tissue!"So after hours of inputting data - and hours or days of going through iterative processes, the computer might be able to come up with an accurate diagnosis, that would take a human physician (and perhaps a few consultants if it is a complicated case) 45 minutes (not counting the time intervals between the various diagnostic studies).After training for 8 - 10 years after a regular college degree, and practicing a few years beyond that, most observation, interpretation, and decision making that a physician does, is done at a subconscious level. For example, I may see a patient sitting in the waiting room and know that they have metastatic prostate cancer - or pancreatic cancer - just by seeing them sitting there. When it's not so obvious, I may need to go through the process of taking a history, performing a physical exam, ordering lab and imaging studies, etc. - that's when it might take an hour. I don't spend all that much of my time doing this at a conscious level.Since most of medicine is practiced at a gut level (the "art" of medicine), it is extremely difficult to tell a computer how to go through all the various processes to arrive at a diagnosis - or to prescribe therapy. Probably the biggest hindrance to getting an AI program to come up with a diagnosis will be putting our clinical instincts into a form that the computer can learn - and then it will only be "as good" as a human physician (or a primary doctor and a few consultants), but it's doubtful it will ever be better.Computers are good at solving problems if they have the information they need - the problem with using them to solve medical problems is that we can't give it that information (at least in a manner that rivals a human physician). It will take years to develop an AI program that can make a diagnosis as well as a human physician - and it will never be as efficient because there's no way (at least at present) to input that data.So far, payment for services has been based (logically) on the cost of providing those services. Computers have allowed us to improve the tools we have for gaining information about patients (CT and MRI were not possible before powerful computers were developed) and treating them (complex therapies such as focused radiation therapy, ablation of ectopic foci giving rise to cardiac arrhythmias, robotic surgery, deep brain stimulation, etc were not possible without computers). With every advance in technology, the cost of healthcare has increased - but the monetary value assigned to a medical procedure shouldn't just depend on how much it costs to perform, it must also require evidence that it improves patient outcomes.So as far as developing AI programs that can make clinical diagnoses - they will certainly be less efficient - and - will add to the expense of administering healthcare. Based on the negative impact IT has already had on a physician's ability to take care of patients, the most helpful advancements in computer programming would be to improve the efficiency of the technology we have already been compelled to adopt.If you are interested in “No Nonsense” answers to serious medical questions, please follow me. (>200 answers on cancer, medicine and human behavior.)..........................

The medical record starts with a history and physical. The history is all the background information the provider can obtain from you. Here is a typical template http://www.westernu.edu/bin/nursing/history-physical-format.pdf .Up to this point, this is everything you already know. You've told the practitioner why you're there, anything about your family's or your medical history, medicines, allergies and how you're body appears to be working.Then the physical exam is performed. In truth, when you read most H & P's, many of the items that are supposed to be examined are glossed over. A good primary care exam should contain every entry, including the dermatologic and neurologic exams. If you're being admitted to the hospital with a broken ankle, the H & P is going to look a lot shorter though the payment is the same. This is a dirty little secret to medicine-if it's was billed as "H & P - comprehensive (see http://www.physicianspractice.com/display/article/1462168/1587145 ) . It is especially true in this age of electronic health records where practitioners can simply hit "default" tabs to suggest that something was examined carefully when in fact it wasn't.Classic examples of such would be the term "grossly intact" for the neurologic exam. It takes some time to examine each crainial nerve, motor and sensory function etc, which is not likely abnormal given the absence of any red flags from the patient supplied "review of systems." Be that as it may, stuff gets missed, particularly in this age of "hospitalist," (hospital employed physicians who care for scores of patients at a time). Having worked in multiple hospitals, I've rarely seen a detailed hospitalist H&P. Typically, they're assuming the doctor who directed the patient to come to the hospital already did it. They then just parrot what they were told on the phone by the referring doc or from the office notes. Please note, this is not always the case. There are many many very good hospitalists. But only you can verify the truth/ completeness of the record.It is not only one's right under HIPAA (http://en.wikipedia.org/wiki/Health_Insurance_Portability_and_Accountability_Act ) to review one's record, it may be useful to see if something got missed.Now the downside. The final part of the H&P is the Impression and Plan. This may contain a list of possible diagnoses to explain some findings. Often, particularly with a good practitioner (MD or nurse practioner), this may include some very unlikely and frightening disease states. They are included for completeness, as they should be. To a lay person, reading it may cause enormous unnecessary stress and confusion. For example, cancer is the great mimicker (also syphilis http://1.usa.gov/ypptkI ).My advice is to let the people you've entrusted your care with to do their job, and only once it is finished review the record for accuracy (if you're so inclined).