Beruflich Dokumente
Kultur Dokumente
_____________________________
Student Name
__________________ UPH__SJCH___UPR___MAZ___
Student Number
Institution
Problem Category #
*SCORE
------------------------------------------------------------------------------------------------------------------------------
PROBLEM
Category Number
1-
2-
Exercise)
(Include Nutritional Assessment Exercise)
3
4
5
6
Hematology Oncology
Chronic Illness
Health Maintenance (Well Baby)
Emergency Acute Care (Include Managed Care Exercise)
UPH____SJCH____UPR_____MAZ
STUDENT'S NAME
NUMBER
PATIENT'S INITIAL
DATES:
INSTITUTION
DATE ADMITTED
WORK-UP HANDED IN
DATE ASSIGNED
PRINCIPAL DIAGNOSIS
PATIENT
PROBLEM CATEGORY
ITEM
1.
2.
3.
4.
*SCORE
(Numerical)
6.
DISCUSSION for the presenting problem the logical reasoning (criteria for or against
a given most likely possible, and accurate ranking of other possibilities; psychological
impact included
DISCUSSION for the problems other than the presenting problems. Includes risks
psychosocial problems and impacts of the presenting illness
WRITTEN REPORT Clarity and organization
7.
8.
INITIAL PLAN OF ACTION comprehensive: includes measures for all the problems
identified and utilizes well the resources available; includes motivational and patient
education aspects to ensure compliance, correct selection of diagnostic and therapeutic
measure. PHARMACEUTICAL EXERCISE - (selected drug, dose, route of
administration, toxicity, indication , contraindication and drugs interaction and a written
model of prescription-requisite of approval of case presentation.) Nutritional
Assessment on General Pediatric Case #3 (see instruction )(Manage Care Exercise on
Case #6 - ER- (see instructions). Radiology Exercise on Case #1 (see Resp.Distress)
FOLLOW UP NOTE includes post assignment information: day, hour, problem
number and name, subjective, objective, assessment and plan. (SOAP)
FUND and sound application of medical knowledge.
5.
9.
10.
** Final Score
(Numerical)
INSTRUCTOR'S NAME
SIGNATURE
*SUMMATIVE SCORE
The sum of the 10 item if each item is graded 7 or
more, and has an (S) satisfactory for all the non
cognitive academic criteria (see format page)
INCOMPLETE - Any of the 10 items is less
than 7 and (S) for the non cognitive academic factors
FAILURE - irrespective of final score. If graded
(U) unsatisfactory in the non cognitive academic
STUDENT NUMBER
CLERKSHIP
NUM.HOURS
DEPARTMENT AND
CLINICAL SETTING
Instructions:
The University of Puerto Rico, School of Medicine recognizes and respects the responsibility of the professional medical school faculty to establish
standards for determining the fitness of medical students to participate in the medical profession. Professionalism Academic non-cognitive factors (ANCF)
will be evaluated separately from and in addition to standard academic abilities such as fund of knowledge. Faculty members who have direct contact
with students in the academic setting will determine the final evaluation of students as satisfactory and unsatisfactory with respect to their academic
non-cognitive attributes.
Evaluation of the Professionalism / ANCF will include the following major criteria (See reverse side for explanations): 1) Personal and Professional
Characteristics; 2) Interpersonal Relationships; 3) Ethical Aspects.
Written documentation of events leading to an unsatisfactory evaluation of a student will be required and may be supported by reports of faculty, peers
or other personnel. An unsatisfactory evaluation and written documentation of events should be forwarded to the Dean, or the appropriate Associate Dean,
as soon as possible. Any student receiving an unsatisfactory evaluation for the Professionalism ANCF will be notified in writing as soon as the Associate
Dean will make possible and a review of the evaluation will be available to the student. The course faculty and the appropriate Promotions Committee will
recommend to the Dean the final action to be taken based on their established rules and regulations.
Evaluation Scale Interpretation: The evaluation rating scale should be interpreted as follow:
SATISFACTORY
See back page for criteria
UNSATISFACTORY - The unsatisfactory grade for the Professionalism/ANCF is obtained if the student fails any of the specified criteria or any
other criteria clearly stated and documented by the preceptor.
ACADEMIC NON-COGNITIVE FACTORS
(Must specify if any criteria is found unsatistactory)
y positive or extraordinary aspect of student.
s
vior is:
U
d Professional Characteristics
ty
nd Initiative
t
Image
Authority
Feedback
of Limitations
l Relationships
_________________________________________________________________________________________________________________________
Date
Academic Period
INSTRUCTOR NAME AND SIGNATURE
Overall Evaluation
SATISFACTORY
RESPONSIBILITY
Consistently prompt and prepared at scheduled
conferences, laboratories work-up presentations,
rounds or any academic and professional activity.
Notifies when unable to attend duties or appointments.
MOTIVATION AND INITIATIVE
Hard-worker and an active leader/participant.
Seeks new learning in educating patient. Uses current
medical information and scientific evidence to improve
patient care.
Shows high interest in educating patient.
Quotes relevant updated medical information.
COMMITMENT
Undertaken duties enthusiastically and perseveres until
complete.
Assumes added responsibilities for patient care or
course load.
PROFESSIONAL IMAGE
Maintains and adequate dress code (as described in
official document: Cdigo de Vestimenta, June 6,
1996).
Able to perform duties even under stressful situations.
RESPONSE TO AUTHORITY AND FEEDBACK
Carries out instructions responsibility.
Accepts academic counseling and guidance.
Modifies performance in response to feedback.
UNSATISFACTORY
RESPONSIBILITY
Consistently late and unprepared at conferences, laboratories
work-up presentations, rounds or any academic and
professional activity.
Does not notifies when unable to attend duties or
appointments.
MOTIVATION AND INITIATIVE
A poor worker. Rarely an active leader/participant.
Avoids new learning experiences. Does not or rarely uses
current medical information and scientific evidence to improve
patient care.
Appears disinterested in educating patient.
Rarely quotes relevant updated medical information.
COMMITMENT
Undertakes duties not enthusiastically. Seems uninterested.
Rarely assumes added responsibilities for patient care or
course load.
PROFESSIONAL IMAGE
Does not maintains and adequate dress code.
(as described in official document: Cdigo de vestimenta, June
6, 1996)
Composure under circumstances of extreme stress is poor.
RESPONSE TO AUTHORITY AND FEEDBACK
Shows resentment to directives of superiors. Does not seek
guidance. When guidance received makes poor introspection
of academic recommendations. Rejects changes of judgements
even when guidance show errors.
RECOGNITION AND LIMITATIONS
RECOGNITION AND LIMITATIONS
Recognizes when to seek help and seeks it out from
Does not ask for help even when it is necessary and does not
appropriate persons.
accept help if offered.
INTERPERSONAL RELATION SHIP *
EMPATHY
Emphatic and sensitive toward the emotional and
personal needs of others.
EMPATHY
Discourteous and insensitive in dealing with the emotional and
personal needs of others.
CONFIDENTIALITY
Omits or disregard institutional rules and regulations.
Does not protect the information trusted to his/her.
RESPECTS OTHERs VULNERABILITY
Does not treat professors, patients and their families, and other
persons with respect and dignity both in their presence and in
discussion with peers and others.
PROBLEM LIST
PREVIOUS ADMISSIONS TO THIS INSTITUTION
(number, date or admission
DATE OF BIRTH:
PROBLEM DESCRIPTION
NO.
APPROX.
ONSET
DATES
ENTERED
RESOLVED OR
INACTIVE
SIGNATURE
NAME OF INFORMANT:
RELATION TO PATIENT:
APPARENT RELIABILITY
___ GOOD
___ QUESTIONABLE
____ POOR
A. CHIEF COMPLAINT
(WITH DURATION) _________________________________________________________________________________
B. PRESENT ILLNESS
C. PAST HISTORY
1. Has your child ever
a. been hospitalized? If yes please list below: ___________________________
b. had an operation? _______________________________________________
c. Non-intentional injuries (specify) __________________________________
d. Hospital
City
Problem
Date
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
2. Please check any of the following diseases that this child has had.
Chickenpox _____________ Hepatitis
_______________
Mumps
_____________
Whooping Cough _______________
Measles _____________
Rubella (German Measles _____________
Other
_____________
Scarlet Fever
________________
PREGNANCY
3. Is mother Rh negative? ____________________________________________
4. Grava ________ Para ________ Abort _________ Living __________
5. Did she have regular medical care while pregnant with this child? ______
6. Did she have any problems while pregnant with this child (such as excessive
bleeding, kidney or bladder infection, high blood pressure, diabetes or high
blood sugar, any operations, convulsions, weight gain over 30 lbs, German
measles, premature labor, x-rays during the first three months, drug abuse any other
illnesses)?
(If yes, write which and explain)
______________________________________________________________
7. Did she take any of the following medications during this patients pregnancy:
(mark those that apply)
_______ Antibiotics
_______ Birth control pills
_______ Fertility pills
_______ Pills to prevent miscarriage
_______ Aspirin
_______ Illegal drugs
_______ Prenatal vitamins
_______ Any other medicines
_______ Alcohol
_______ Smoking
8. Did she have an unusually long or difficult labor with this child? ________
9. Did the mother had this test done during pregnancy?
________ HIV Test _________ VDRL ________ Heb Surface Antigens
BIRTH
10. Was this child born in a hospital? __________________________________
11. Was this child born by cesarean section? ____________________________
12. How much did this child weight at birth? ________ Lbs. ________ Oz.
13. Were there any problems with this childs delivery? Specify if yes
14. Was this child born with any birth defect?
15. Did this child go home from the hospital at the same time as mother did?
16. Did this child have any unusual problems in the hospital (such as blue spells
(cyanosis), yellow jaundice, trouble breathing, trouble feeding, infection,
convulsions, or any other illness)? (Specify if yes)
____________________________________________________________
17. Did this child need any special treatment while in the hospital (such as
incubator, oxygen, blood transfusion, medicines, feeding with a tube, or any
other unusual treatment)? _______________________________________
ADDITIONS:
D. PERSONAL HISTORY
PATIENT PROFILE
17. Is this child adopted? _____________________________________________
18. If this child goes to school, please give
Name of school __________________________________________________
Town __________________________________________________________
Grade __________________________________________________________
Teachers name __________________________________________________
Grades at last marking period _______________________________________
Trend of performance (improving, stable, deteriorating) __________________
PERSONALITY
19. How would you describe your child?
Happy __________________ Yes
Cooperative ______________ Yes
Usually obedient __________ Yes
Fearful __________________ Yes
Destructive _______________ Yes
Difficult __________________ Yes
No
No
No
No
No
No
Irritable_______________
Too active ____________
Too lazy ______________
Shy __________________
Nervous ______________
No
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
FAMILYGRAM
F. REVIEW OF SYSTEM
GROWTH- ENDOCRINE
42. Was this child born-on time? (specify weeks of gestation) _________________________
43. Have you ever thought that this child was growing too slowly? _____________________
-too rapidly? ____________________
44. Have you ever thought that this child was - too fat? ______________________________
- too thin? _____________________________
45. Has this child lost weight that he/she has not regained? ___________________________
46. Has this child ever had trouble with the thyroid gland? ___________________________
47. Has this child ever taken a thyroid drug? _______________________________________
48. Does a tendency for obesity (being overweight) run in this childs family?
49. Does this child have a blood relative with a sex abnormality? ______________________
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
VISION
59. Has this child ever
-had trouble seeing? _____________________________________________________
-worn glasses? __________________________________________________________
-had an eye which turned in or out? __________________________________________
No
No
No
Yes
Yes
Yes
DEVELOPMENT
50. Do you think that this childs mental development is normal? ______________________
51. If in school, has this child had trouble keeping up with his/her classmates? ____________
52. Do you think that this child is too clumsy? _____________________________________
53. Did this child a. smile by six weeks of age? ___________________________________
b. sit alone by seven months? ___________________________________
c. walk alone by 14 months? ____________________________________
d. say simple sentences by age of two years? _______________________
e. ride a tricycle by age of three years? ____________________________
f. tie his own shoelaces by age of six years? ________________________
54. Has this child ever had to repeat a school grade? ________________________________
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
ADDITIONS:
RESPIRATORY
60. In the past year has this child had
-more than six colds __________________________________________________________
-a persistent runny nose? ______________________________________________________
-a cough that hangs on? _______________________________________________________
-pneumonia? ________________________________________________________________
-an asthma attack? ___________________________________________________________
-wheezing? _________________________________________________________________
-shortness of breath? __________________________________________________________
-frequent sore throats? ________________________________________________________
61. Has this child ever
-had asthma? _______________________________________________________________
-had a positive skin test for tuberculosis (tuberculin or PPD)? _________________________
-been around a person with tuberculosis? __________________________________________
62. Does anyone in the household smoke? ____________________________________________
CARDIOVASCULAR
63. Has this child ever had
-a heart murmur? ____________________________________________________________
-cyanosis (blue spells)? _______________________________________________________
-an extremely rapid or irregular heart beat? ________________________________________
-rheumatic fever? ____________________________________________________________
64. Has this child had a blood relative with
-a heart attack under age 50? ___________________________________________________
-a heart attack over age 50? ____________________________________________________
-elevated blood fats (cholesterol or triglycerides)? __________________________________
-high blood pressure? _________________________________________________________
-a stroke under age 60? ________________________________________________________
-a stroke over age 60? _________________________________________________________
65. Does the child have a throat culture taken when he she has a sore throat to check for a strep
throat? ___________________________________________________________________
GASTROINTESTINAL
88. Has this child ever had
-recurrent stomachaches? ______________________________________________________
-recurrent vomiting? __________________________________________________________
-recurrent diarrhea? ___________________________________________________________
-recurrent constipation? _______________________________________________________
-blood in his/her bowel movement? ______________________________________________
-medicine for stomachaches or constipation? _______________________________________
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Use this
column to
specify,
clarify or add
any
information
89. Has this child ever had x-rays of the stomach or intestines? ____________________________
GENITOURINARY
90. Has this child ever
-had a bladder or kidney infections? ______________________________________________
-had trouble with pain on urination, increased urinary frequency or loss of control? ________
-had trouble with bedwetting? __________________________________________________
-had bloody or smoky-colored urine? _____________________________________________
-had x-rays of the kidney or bladder? _____________________________________________
Girls 10 years or older
91. Does this girl have an excessive vaginal discharge? __________________________________
92. Is this girl having menstrual periods? _____________________________________________
93. Are there problems with her periods? _____________________________________________
94. Does this girl understand menstruation? __________________________________________
95. Does this girl understand contraception? ___________________________________________
96. Does this girl understand sex problems? ___________________________________________
97. Do you want this girl to receive sex education? _____________________________________
HEMATOLOGIC SYSTEM
No
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
N/A
N/A
N/A
N/A
N/A
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
SKIN
103. Has this child ever had any skin problems? ___________________________
Yes
No
MUSCOLOSKELETAL
Has this child ever had
104. Painful or swollen joints? _________________________________________
105. a broken bone? _________________________________________________
106. a limp? _______________________________________________________
107. treatment for a bone, joint or muscle problem? ________________________
Yes
Yes
Yes
Yes
No
No
No
No
NEUROLOGIC
Has this child ever had
108. troublesome headache, loss of consciousness, a seizure or a convulsion?
109. Does this child eat paint chips, plastes or putty? _______________________
Yes
Yes
No
No
Yes
No
G. HEALTH MAINTENANCE
HEALTH MAINTENANCE (as applicable for age)
111. Where does this child usually go for medical care? _______________________________
________________________________________________________________________
112. When was this childs last complete checkup and who performed it? _________________
_________________________________________________________________________
113. What did this child eat yesterday (or the last day he (she) was well)?
Breakfast ______________________________________________________________
Lunch ________________________________________________________________
Dinner ________________________________________________________________
Snacks ________________________________________________________________
114. Was (Is) this child breast-fed? ________________________________________________
115. Does this child take vitamins? ________________________________________________
116. Does this child take iron medicine? ____________________________________________
117. Does this child drink more than a quart of milk per day? ___________________________
118. Does this child brush his/her teeth regularly? ____________________________________
119. Does this child use dental floss regularly? _______________________________________
120. Does this child drink fluoridated water or take fluoride supplements? _________________
121. Has this child been to the dentist in the past two years? ____________________________
122. Does this child, if under 4, ride in a safe car seat? _________________________________
123. Do you and your children over 4 use seat belts in the car? __________________________
124. Does this child have a bike? __________________________________________________
125. Does he use a helmet when bike or skate riding? _________________________________
126. Does this child use a lifejacket when boating? ___________________________________
127. Does this child know how to swim? ___________________________________________
128. Do you have firearms at home? _______________________________________________
129. If they; are they kept out of reach of children? ________________________________
130. Does this child operate, play or work with heavy duty machinery? ___________________
131. Do you have a record of immunizations? _______________________________________
132. Please list the dates or approximate ages at which this child received the following
immunizations: (provide dates if known)
DTaP
1 ______ 2 _______ 3 _______ 4 _______ 5 _______
IPV
1 ______ 2 _______ 3 _______ 4 _______
MMR
1 ______ 2 _______
Prevnar
1 ______ 2 _______ 3 _______ 4 _______
Varicella
1 ______ 2 _______
Hibtiter
1 ______ 2 _______ 3 _______ 4 _______
Hepatitis B
1 ______ 2 _______
Influenza
1 ______ 2 _______ 3 _______
Meningococcus 1 ______
Others
1 ______
133. Has this child been tuberculin tested ___________________________________________
If yes, indicate (PPD) date __________________________________________________
and results _______________________________________________________________
134. Does this child get regular physical exercise? ____________________________________
135. Does this child use, or has used in the past, alternative medicine or procedures (Ej.
Santiguo, herbal medicine, naturopathic medicine, etc.)?
ADDITIONS:
A must for patients 12 years or older:
For the adolescent patient add (in an extra paper if necessary) the following essential
information: concerns with the developing body; peer relationship and social interaction;
attitudes towards parental authority; dietary and self care habits; sexual activity and habits;
aggressive or involved in violent acts; affective behavior; suicidal ideation and attempts; habits
to include use of alcohol, cigarettes, illicit drugs and steroids; body and gender image and self
confidence.
For details refer to the Guidelines for Health Supervision for Pediatric Patients ages 0-20
yrs American Academy of Pediatrics.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
Yes
Yes
No
No
No
ECOMAPA:
STRENGTH, VULNERABILITIES AND SUPPORT SYSTEM DIAGRAM: LIFE EVENTS, DATES AND
CORRESPONDING PATIENTS AGE
Describe parents and patients (if old enough) ideas and feelings as to nature, cause and diagnosis of the presenting illness. Describe
family conceptions or misconceptions of health problems, procedures and medications. Indicate how these seem to be affected by
cultural patterns.
FOR EACH SYSTEM CHECK EXAMINED: NORMAL, ABNORMAL NOTE AND DESCRIBE ANY ABNORMALITY IN DETAIL
SYSTEM AND CRITERIA OF NORMALITY
SKIN
Color: clear, no jaundice, pallor, cyanosis, rashes or abnormal
pigmentations, petechiae, purpuras.
Texture and Feel: normal
Good Turgor: no edema or nodules.
EYES
Sclerae and Conjunctiva: clear. No jaundice injection or
exudates.
Pupils: round, equal, reactive to light.
Media: comes clear, no cloudiness nor cataracts.
EOM: intact.
Fundi: discs sharp, normal in color. Retinal arteries and veins
normal. No hemorrhage or exudates.
EARS
External ears and canal: clear shape normal
TM: clear, normal gray color with landmarks visible. No bulging,
perforation, scarring.
Hearing: grossly normal.
Mastoid: no tenderness or swelling.
Percussion: normal.
GENITALIA Describe Tanner Staging
Male: normal development for age. Penis, scrotum and testicles are normal.
No epispadias, swelling, phimosis or discharges.
* NEUROLOGICAL
Cerebral Function: mental status and development for age.
(See instructions)
Meningeal: signs not present (neck supple, no Kernig, Brudzinski, tense
fontanel).
Cranial Nerves: (I-smell; II-vision, visual fields, fundi; III, IV, VI-extra
ocular muscles; V-jaw, corneal reflexes; VII-facial;
VIII-hearing; IX-X-palate, gag, swallowing; XI-spinal
accessory, neck; XII-tongue) intact.
Normal Sphincters
Sensory: no deficits.
* MENTAL SCREENING AND DEVELOPMENT FOR AGE EXAMINATIONS
Record findings objectively following the guidelines for persons ages 0-6 yrs, or the one for persons > 6 yrs.
DISCUSSION
1. DISCUSS DIFFERENTIAL DIAGNOSIS OF PATIENTS PRESENTING PROBLEM (AT LEAST 3 IN ORDER
OF PROBABILITY).
S:
O:
A:
P:
MD Name: ______________________________________________________________
MD Address: ____________________________________________________________
____________________________________________________________
MD telephone #: _________________________________________________________
Patients Initials: __________________________________________________________
Patients Address: _________________________________________________________
Patients Age: ____________________________ Patients Weight: _________________
Date: ___________________________________________________________________
Rx:
Sig:
Disp:
_____________________________
MD Signature
_____________________________
MD State License
______________________________
BNDD
(To use for narcotics and other restricted drugs)
_______________________________
DMD
(To use for narcotics and other restricted drugs)
Date:
____________________
Diagnosis: ____________________
____________________
Infant (0 2 y/o) Child (3 11 y/o) Adolescent (12 y/o)
Problems:
Nausea
Chewing difficulties
Swallowing difficulties
Diarrhea
Vomiting
Anorexia
Abdominal Pain
Constipation
Others:_____________________
_____________________
Screening:
1. Assess familys sociocultural factors linked to excess weight.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
2. Assess family history of excess weight. _________________________________________
___________________________________________________________________________
3. Assess hours per day of T.V. viewing, video games or computers (child or adolescent only).
___________________________________________________________________________
4. Assess hours per day of physical activities, and what kind.
___________________________________________________________________________
5. Was patient born prematurely? Yes: ______weeks (gestational age)
6. Illness: Acute
No
Chronic
Nutritional History:
1. Diet (0 2 years):
Breast Milk:
feeds/day________________ duration of each feed:_______
Formula: ________________ ounces per day: ____________
b. Current weight:_______Ptile:_________
e. Current length or height: ____Ptile: ____
g. Current height for age, Ptile: __________
RR: ________
Laboratories:
a. Hgb: ______________
d. Total protein: _______
f. Total Cholesterol: ____
j. Triglyceride: _________
m. Other: _____________
BP:________
b. Hct: ______________
e. Albumin: __________
g. HDL: _____________
k. BUN: _____________
Assessment:
a. Nutritional Risk (explain below): Yes No
________________________________________________________________________________
b. Estimated nutrient requirement (kcal/day):_______________________
c. Estimated desirable body weight: ______________________________
Recommendations (Plan):
Answer the questions below using the following managed care principles:
Risk distribution
Catastrophic coverage
Stop loss
Case management
What is the patients principal diagnosis? Identify and copy the ICD9 codification for this
diagnosis.
2.
Select a treatment or diagnostic procedure, identify and copy its CPT4 codification (e.g.,
ABGs, Veni-puncture, Bone Marrow, or any other procedure performed on the patient).
3.
What are the managed care implications of correctly identifying and recording the
patients principal diagnosis in the medical record? Explain briefly in a short narrative.
4.
Why is it important to send a summary to the patients primary physician? What are the
implications of not sending the summary?
5.
What information should be included in the summary? Write an outline of what must be
included in this kind of summary.
6.
7.
What criteria should be utilized and steps followed to enroll this case in the proper
healthcare coverage within the government health plan (i.e., regular orcatastrophic
coverage)? (Do the exercise even if the patient already has the coverage)
RADIOLOGY EXERCISE
This exercise must be done in the work-up presentation of the newborn patient with respiratory
difficulty or problem. Case #1
1-
Mention specific history findings and criteria that contributes to define the most probable
diagnosis in this patient
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_____________________
2-
Mention specific physical exam findings and criteria that contributes to define the most
probable diagnosis in this patient include vital signs and O2 saturation.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________
34-
Discuss chest X rays of assigned patient with neonatology faculty, pediatric faculty or
resident.
Discuss chest X rays with assigned hospital radiologist
Radiologist signature:_______________________________________________
5-
6-
7-
Mention the most likely diagnosis for this patient taking into account history , physical
exam and radiologic findings:
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