PATIENT HISTORY AND
PHYSICAL EXAM (PHYSICIAN)
Chapter 16
OBJECTIVE
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Document the patient’s history and physical
exam findings
KEY CONCEPTS
History of the chief complaint
 Extended history
 Review of systems
 Past history
 Family history
 Social history
 Physical exam
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PATIENT HISTORY AND PHYSICAL EXAM
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History and Exam section on Visit Documentation
screen
Used for physician to document patient’s history and
physical exam findings
Only section that does not need to be completed prior
to discharging patient
All other sections are required
History and exam questions based (problem-focused)
on diagnoses selected by physician
If multiple diagnoses MedTrak prepares blended
checklist of history/exam questions from head to toe
Questions common to each diagnosis of a multiplediagnoses patient visit only appear once in checklist
Do This! Pg. 198
DOCUMENTING THE HISTORY AND EXAM
BASED ON THE DIAGNOSIS
Place cursor in History and Exam field on Visit
Documentation screen (Figure 16-1)
 Click History and Exam button to display Doctor
Checklist Processor screen(Figure 16-2)
 Screen displays names of doctor’s checklists that
correspond to diagnoses selected by physician
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3 WAYS PHYSICIAN CAN ANSWER HISTORY
& EXAM QUESTIONS
1. Dictation Topic: physician dictates
history/exam questions
 2. Detail Questions: physicians use keyboard to
type answers using a detailed checklist of
questions
 3. Checkboxes: physicians use wireless tablet
computer into exam room and check off answers
on touch screen while examining patient
 Do This! Pg. 200
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ANSWERING QUESTIONS USING THE
MACRO METHOD
Click Questions(macro) button on Doctor’s
Checklist Processor screen(Figure 16-3)
 Top section of buttons on left side of screen for
reviewing the on-line chart and answering
questions
 Lower section of buttons for navigating list of
questions
 Do This! Pg. 201
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ANSWERING QUESTIONS USING THE
DETAIL METHOD
Click Questions (detail) button on Doctor’s
Checklist Processor screen(Figure 16-4)
 Top section of buttons on left side of screen for
reviewing online chart and answering questions
 Lower section of buttons for navigating list of
questions
 Do This! Pg. 202
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ANSWERING QUESTIONS USING THE
CHECKBOXES METHOD
Click Check Boxes button on Doctor’s Checklist
Processor screen
 MedTrak builds screen with triggers to questions
appearing to right of questions with checkboxes
in front of triggers for selection purposes
 Answer questions by checking trigger checkboxes
 Some questions answered simply by checking one
or more trigger checkboxes and others may
require going to Expanded Answer screen to
enter more specific answers
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TRIGGER CHECKBOXES
FIGURE 16-5 AND 16-6
Source of History: patient
Onset of symptoms: immediate
Progression of symptoms: increased
Any previous treatment: none
Frequency of pain: constant
Description of pain: sharp
Location of pain: lateral
Severity @ rest: moderate
Severity w/ activity: severe
Normally, physician would click described checkboxes to
answer Chief Complaint and History of the Chief
Complaint using Expanded Answer screen(but not in
the example)
VISIT CHART
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Click Submit button to record selections and stay on
same screen or click Page Down button to submit
changes and move down the checklist to next set of
questions of following screen
Review answers using the on-line chart, click On-Line
Chart button on Doctor’s Checklist screen
(Figure 16-6)
On-line chart has navigation buttons to reset specific
sections of chart and plus and minus signs to use for
expanding/collapsing sections of chart
After reviewing on-line chart click Exit Chart button
and return to Doctor’s Checklist checkbox processor
Do This! Pg. 204-212
PRINTING THE PATIENT’S CHART
You will need to print and turn in the patient
history and physical examination documentation
for the patient that you completed in the
electronic health record
 Do This! Pg. 213
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