Document any history of pertinent surgeries or procedures
6
Identify any family history of diseases related to each system
7
Monitor and record the patient's vital signs
8
Conduct physical examination of each system
9
Document findings from the physical examination
10
Review patient's recent lab results and diagnostic tests related to each system
11
Record any allergies or adverse reactions to medications
12
Review patient's social history including habits and lifestyle
13
Assess patient's psychological and emotional well-being
14
Identify any concerns or risks related to each system
15
Approval: Doctor for initial findings
16
Prepare preliminary review report
17
Discuss findings with the patient and answer queries
18
Plan following steps or treatments based on the review of systems
19
Approval: Patient for treatment plan
20
Close Review of Systems process
Initiate Review of Systems process
This task is the first step in the review of systems process. It sets the stage for the entire workflow. The goal is to initiate the process by gathering the necessary information and resources to conduct a comprehensive review of the patient's systems. This task includes identifying the patient, scheduling necessary appointments, and preparing the required forms.
Identify systems for review
This task involves identifying the systems that need to be reviewed for the patient. The goal is to categorize the patient's symptoms and complaints into the relevant systems for a structured review. By doing so, it helps in organizing the process and ensuring that no system is overlooked.
1
Cardiovascular
2
Respiratory
3
Gastrointestinal
4
Musculoskeletal
5
Endocrine
Gather and review patient's clinical history
This task involves gathering and reviewing the patient's clinical history. The goal is to understand the patient's medical background, previous illnesses, and treatments. By reviewing the clinical history, it provides insights into potential risk factors and underlying conditions that may contribute to the patient's current symptoms.
Record current symptoms related to each system
This task involves recording the current symptoms related to each system identified earlier. The goal is to document the patient's specific complaints and gather detailed information about the symptoms. By doing so, it helps in conducting a thorough review and identifying any patterns or correlations between the symptoms and the systems under review.
1
Chest pain
2
Shortness of breath
3
Palpitations
4
Swelling in the legs
5
Fatigue
1
Cough
2
Wheezing
3
Shortness of breath
4
Chest tightness
5
Sputum production
1
Abdominal pain
2
Nausea
3
Vomiting
4
Diarrhea
5
Constipation
1
Joint pain
2
Muscle weakness
3
Swelling
4
Stiffness
5
Limited range of motion
1
Fatigue
2
Increased thirst
3
Frequent urination
4
Weight changes
5
Changes in appetite
Document any history of pertinent surgeries or procedures
This task involves documenting any history of pertinent surgeries or procedures undergone by the patient. The goal is to gather information about any previous surgical interventions or medical procedures that may have an impact on the patient's current symptoms or conditions. By documenting this history, it provides context for the review process.
Identify any family history of diseases related to each system
This task involves identifying any family history of diseases related to each system under review. The goal is to gather information about genetic predispositions or familial patterns that may contribute to the patient's current symptoms or conditions. By identifying such family history, it helps in assessing the patient's risk factors.
1
Yes
2
No
3
Don't know
1
Yes
2
No
3
Don't know
1
Yes
2
No
3
Don't know
1
Yes
2
No
3
Don't know
1
Yes
2
No
3
Don't know
Monitor and record the patient's vital signs
This task involves monitoring and recording the patient's vital signs. The goal is to assess the patient's overall health status and detect any abnormalities or variations from the normal range. By monitoring vital signs, it helps in evaluating the patient's physiological condition and providing relevant data for the review.
Conduct physical examination of each system
This task involves conducting a physical examination of each system under review. The goal is to perform a systematic evaluation of the patient's body, focusing on specific areas and organs related to each system. By conducting a physical examination, it helps in identifying abnormalities, detecting signs of disease, and gathering more information for the review.
1
Cardiovascular system
2
Respiratory system
3
Gastrointestinal system
4
Musculoskeletal system
5
Endocrine system
Document findings from the physical examination
This task involves documenting the findings from the physical examination conducted earlier. The goal is to record the observations, measurements, and any abnormalities or notable findings related to each system. By documenting the examination findings, it helps in creating a comprehensive record and providing a reference for future assessments or comparisons.
Review patient's recent lab results and diagnostic tests related to each system
This task involves reviewing the patient's recent lab results and diagnostic tests related to each system. The goal is to gather objective data from laboratory tests, imaging studies, or other diagnostic procedures to complement the subjective information gathered earlier. By reviewing these results, it helps in confirming or ruling out possible conditions and providing a more comprehensive assessment.
Record any allergies or adverse reactions to medications
This task involves recording any allergies or adverse reactions to medications experienced by the patient. The goal is to identify potential allergies or sensitivities that may affect the patient's treatment or further investigations. By documenting this information, it helps in ensuring the patient's safety and avoiding any potential complications.
Review patient's social history including habits and lifestyle
This task involves reviewing the patient's social history, habits, and lifestyle. The goal is to gather information about the patient's daily routines, living conditions, and activities that may have an impact on their health. By reviewing this social history, it helps in understanding potential risk factors, identifying unhealthy habits, and considering lifestyle modifications.
1
Single
2
Married
3
Divorced
4
Widowed
5
Living with partner
1
Office job
2
Manual labor
3
Healthcare
4
Education
5
Unemployed
1
Smoking
2
Alcohol consumption
3
Exercise routine
4
Dietary preferences
5
Sleep patterns
Assess patient's psychological and emotional well-being
This task involves assessing the patient's psychological and emotional well-being. The goal is to evaluate the patient's mental health, emotional state, and overall psychological well-being. By assessing these aspects, it helps in understanding the patient's holistic health and identifying any underlying psychological factors that may contribute to their symptoms.
1
Happy
2
Sad
3
Angry
4
Anxious
5
Neutral
1
Low
2
Moderate
3
High
4
Very high
5
Extremely high
Identify any concerns or risks related to each system
This task involves identifying any concerns or risks related to each system under review. The goal is to assess the patient's specific risks, vulnerabilities, or potential complications associated with their symptoms and medical condition. By identifying these concerns or risks, it helps in planning appropriate interventions or preventive measures.
Approval: Doctor for initial findings
Will be submitted for approval:
Gather and review patient's clinical history
Will be submitted
Record current symptoms related to each system
Will be submitted
Document any history of pertinent surgeries or procedures
Will be submitted
Identify any family history of diseases related to each system
Will be submitted
Monitor and record the patient's vital signs
Will be submitted
Conduct physical examination of each system
Will be submitted
Document findings from the physical examination
Will be submitted
Review patient's recent lab results and diagnostic tests related to each system
Will be submitted
Record any allergies or adverse reactions to medications
Will be submitted
Review patient's social history including habits and lifestyle
Will be submitted
Assess patient's psychological and emotional well-being
Will be submitted
Identify any concerns or risks related to each system
Will be submitted
Prepare preliminary review report
This task involves preparing a preliminary review report based on the gathered information and assessments. The goal is to summarize the findings, observations, and key points from the review process. By preparing this report, it helps in maintaining an organized record and facilitating communication with other healthcare professionals involved in the patient's care.
Discuss findings with the patient and answer queries
This task involves discussing the findings of the review with the patient and addressing any queries or concerns they may have. The goal is to provide the patient with a clear understanding of the review results, their implications, and potential next steps. By engaging in this discussion, it fosters patient collaboration and enables informed decision-making.
Plan following steps or treatments based on the review of systems
This task involves planning the following steps or treatments based on the findings from the review of systems process. A comprehensive understanding of the patient's health status is essential for developing an appropriate plan. The task should address the criteria or guidelines for determining the next steps or treatments. How will you prioritize the identified concerns? What factors will influence the treatment planning?
Approval: Patient for treatment plan
Will be submitted for approval:
Prepare preliminary review report
Will be submitted
Discuss findings with the patient and answer queries
Will be submitted
Plan following steps or treatments based on the review of systems
Will be submitted
Close Review of Systems process
This task marks the end of the review of systems process. It involves closing any open documentation, submitting the final report, and ensuring proper storage of all related information. The task requires attention to detail and adherence to organizational protocols. How will you ensure the completion and accuracy of all documentation? What storage or archiving procedures should be followed?
