Phase of Encounter (01_Codes)
Physical Exam (02_PE)
descriptive information mentioned (03_PE_descriptive)
weight, BCS
CRT, MM
TPR
attitude
systems examined (03_PE_systems)
General Appearance
Integumentary
Ophthalmic
Otic
Musculoskeletal
Cardiovascular
Respiratory
Reproductive
Mammary
Urinary
Nervous
Alimentary
Lymphatic
Planning (02_Planning)
Initial Plan (03_Tx_Plan_Proposed)
considers patient status
considers client perspective
matches data obtained
follows logically from presumptive diagnosis
Diagnostic Tests Requested (03_Case_Name)
Jade (05_Jade_diagnostics2) Note: 06_requested is where Dx tests are selected
CBC
chem
UA (05_Jade_UA)
free catch
cysto
urine culture
PCV/TS
Snap 4DX
renal values post IV fluids
abdominal radiographs
thoracic radiographs
abdominal ultrasound
cortisol
ACTH stim
fecal
GI panel
SDMA
T4
VBG
Lepto
histoplasmosis
pythium serology
Max (05_Max_diagnostics2)
CBC
chem
UA (05_Max_UA)
free catch
cysto
ultrasound-cysto
urine culture
abdominal radiographs
urethra stone check
abdominal ultrasound
LDDS
ACTH stim
Lepto
fecal
Tiger (05_Tiger_diagnostics2)
CBC
chem
UA (05_Tiger_UA)
free catch
cysto
urine cultrue
UPC
FeLV/FIV
GI panel
blood pressure
T4
abdominal radiographs
thoracic radiographs
abdominal ultrasound
LN FNA
PARR
fecal
Giardia wet mount
tritichomonas
Diagnostic Review (02_DxReview)
additional tests requested (05_Case_Name2)
desired client communication
case summary (code for communication - 02_ReflectiveListening)
Demonstrations of Reasoning (01_Codes)
Subsequent Hypothesis (02_Hypothesis) in comments list hypothesis
Hypotheses during encounter
level of specificity (03_HypothesisLevel)
disease process
specific disease (AKA differential)
confidence (03_HypothesisConfidence)
high (8-10)
medium (4-7)
low (1-3)
action (re-prioritize) (03_HypothesisPrioritize)
increase confidence
decrease confidence
final dx (03_Final_Dx)
correct (list in comments)
incorrect (list choice in comments)
Use of Data (02_UseOfData)
data noted by participants as "missed" (e.g. I wish I'd asked about...)
data acquired (03_DataObtained)
acknowledged verbally
took into consideration
missed opportunity
Type of Prior Knowledge (02_KnowledgeTypes)
basic sciences (03_KnowledgeRight)
stated correctly
stated incorrectly
applied correctly
applied incorrectly
clinical sciences (03_KnowledgeRight)
stated correctly
stated incorrectly
applied correctly
applied incorrectly
CR process (03_KnowledgeRight)
stated correctly
stated incorrectly
applied correctly
applied incorrectly
communication process (03_KnowledgeRight)
stated correctly
stated incorrectly
applied correctly
applied incorrectly
referral to literature (03_KnowledgeRight)
stated correctly
stated incorrectly
applied correctly
applied incorrectly
Communication and CR (01_Codes)
Reflective listening (02_ReflectiveListening)
paraphrasing (lay terms)
confirmation/clarification of client statements (add comment)
empathy
Question (03_Question)
open
closed
diagnostic tests reviewed (04_Case_Name2)
Max
Jade
Tiger
list of Dx tests (07_Max_diagnostics2)
list of Dx tests (07_Jade_diagnostics2)
list of Dx tests (07_Tiger_diagnostics2)
Max
Tiger
Jade
list of Dx tests (06_Jade_diagnostics2) - 06_Jade_UA
rationale to interviewer (06d_rationale_to_interviewer)
list of Dx tests (06_Max_diagnostics2)
(06d_rationale_to_interviewer)
list of Dx tests (06_Tiger_diagnostics2)
lymph node cytology
sign-posting (previewing, transitioning, structuring)
:
not determined (list choices under consideration)
fecal smear
full tick panel
lymph node aspirate
USG
History (02_History)
elicited information (02a_elicited info)
verbal prompt - type of question (03_Question)
open
content of Q (03_Content)
biomedical (04_BiomedicalContent)
systems review
client perspective
background (04_BackgroundInformation)
diet
prior med/surgical
medications
lifestyle, environment
use/purpose
spontaneously volunteered
content of statement (03_Content)
client perspective
background info (04_BackgroundInformation)
biomedical (04_BiomedicalContent)
systems review
analysis of clinical signs
sequence of events
prior med/surgical
medications
lifestyle, environment
use/purpose
diet
presenting complaint
sequence of events
presenting complaint
closed
content of Q (03_content)
background information (04_BackgroundInformation)
medications
lifestyle, environment
prior med/surgical
use/purpose
diet
analysis of clinical signs
client perspective
Initial Assessment (02_Assessment)
case summary (EOC, w/comment)
initial hypotheses (02a_Initial_Hypothesis) - Enter hypothesis in comments!!!! ... analysis continues under CR
level of concern (03_Concern_Level)
additional history (02_History)
rationale
yes
no
empathy statements
Hx and PE Problems (02_Problems)
refinement of problems (03_ProblemRefinement)
problem discarded
problem refined/restated (reducing # of problems, making more specific)
grouping of diagnostic information (from all over)
use of semantic qualifiers (acute/chronic)
integration and synthesis (02_Integration)
problem list
if yes, launch questionnaire
problem abandoned
needed (I didn't know)
applies ALL information relevant to patient
relates problems on problem list to each other
yes
no - what missed
incorrect- used wrong
Initial Hypothesis (before entering room)
system
reasonable
level of specificity
confidence
no
yes
system
disease process
specific disease
medium (4-7)
low (1-3)
hypothesis reasonable (during process) (03_HypothesisReasonable)
yes
no
high (8-10)
systematic approach (03_Systematic_Approach)
specific to patient
cookbook
none
Pre-Introduction (02_Pre-Introduction)
pre-conceived ideas based on signalment and presenting complaint (e.g. pattern recognition, illness scripts)
semantic qualifiers - note terms used
level of concern (03_Concern_Level)
moderate (4-7)
low (1-3)
high (8-10)
Home Care Plans - enter the proposed interventions
Empirical Treatment - enter the proposed treatment(s)
Introduction (comments only)
requested (06_requested)
rationale to client? (06c_rationale_to_client)
test received (06b_received)
Approach to Interpretation (04_Systematic_Approach)
results percieved
Systematic Approach (04_Systematic_Approach)
no (relevant results not percieved)
yes (02_Knowledge_types)
rationale to interviewer (06d_rationale_to_interviewer)
Systematic Approach (04_Systematic_Approach)
requested (07_requested)
rationale to interviewer (07d_rationale_to_interviewer)
received (07b_received)
Systematic Approach (04_Systematic Approach)
requested (07_requested)
rationale to interviewer (07d_rationale_to_interviewer)
received (07b_received)
Systematic Approach
requested (07_requested)
rationale to interviewer (07d_rationale_to_interviewer)
received (07b_received)
Systematic Approach
non-verbal encourager (03_content)
client perspective
background info (04_BackgroundInformation)
biomedical (04_BiomedicalContent)
analysis of clinical signs
systems review
sequence of events
presenting complaint
lifestyle, environment
use/purpose
diet
medications
prior med/surgical
rationale to client (06d_rationale_to_client) (yes/no)
rationale to client (06d_rationale_to_client) (yes/no)
inappropriate use of medical terminology
summarize
all
one
all
one
one
one
one
one
some
one
all
some
problem identification (03_ProblemIdentification) - enter problem in comments
one
extra/inaccurate info (list what they made up)
yes
no
one
all
some
some
one
one
one
one
one
02_metacognition
some
draws on prior experience
error avoidance
uses minimal mental resources (unconsciously competent)
reports overwhelmed/high cognitive load
thinks about how to manage encounter
ID's areas for growth
one
some
multiple passes - full classification for each Q
one
one
one
one
some
some
some
some
some
some
some
need to do some type of checklist for each test:
was it requested?
rationale to client? (yes/no does not determine next step)
test received? - it would be nice to carry this info to review branch.
some
some
one
one
this is the same list of tests for each case, shown above. For each test ordered (e.g. CBC), we need to note the following:
- was a rationale provided to the interviewer
- the approach used to interpreting the test (systematic, generic, etc)
- for each grouping of results (major, fair, minor), need to check off things that were perceived
- for each item that was perceived, need to note if the interpretation was correct AND the type of knowledge used
one
see list of interpretation items, above
some
some
some
some
biomedical (04_BiomedicalContent)
some
sequence of events
presenting complaint
systems review
analysis of clinical signs
some
some
some
some
some
some
some
moderate (4-7)
low (1-3)
high (8-10)
one
does not match data obtained
does not follow logically
this is the only way I could figure out to bring up different lists of diagnostic tests for different patients
one
click to edit
one
relates problems to final diagnosis
builds rapport (fir logic, consider under comm)
restated presenting complaint