Missing Data – Do you need more information in order to develop a plan? If so, what information do you need or want? (Can be bullet points)
Example – Chest pain
Family history of cardiovascular disease?
Psychosocial issues – smoking, caffeine intake, ETOH or substance use/abuse?
Chest pain/discomfort – how does the patient characterize it?
Physical exam – presence of murmurs, extra heart sounds, lower extremity edema?
Interpretation of Cues, Patterns, and Information – Do patterns emerge when analyzing the subjective and objective information? (Can be bullet points)
Example – Chest pain
Clustering data – Are the data forming clusters that can assist in the development of a problem list?
Pain occurs in sternum, pain radiates to neck, patient also experiencing dyspnea and diaphoresis; pain not reproducible with palpation of chest wall
Hypothesis generation – What hypotheses have you generated as you examine the data?
cardiac problems vs musculoskeletal chest pain vs GERD vs pulmonary disorders
Differential Diagnoses – include 3 differential diagnoses including ICD-10 codes. (Can be bullet points)
Example – Chest pain RO7.9
Precordial Pain – R07.2
Acute Myocardial Infarction – I21.9
Gastroesophageal Reflux Disease without esophagitis– K21.9
Final Diagnosis - what is the most probable cause of the patient problem?
Management Plan – this is related to your final diagnosis (Paragraph Form or Bullet Points)
Pharmacological
Nonpharmacological
Diagnostics
Educational
Social Determinants of Health
Follow up – when should this patient return to the office? What conditions would need earlier follow up? (Paragraph Form)
