FINAL ND Module 09-10.pdf - AaronsWorld.com

and ate at local restaurants and stands. I did not have access to bottled water, but I have an old
filter I used to use when I went camping.) .
It should include the attributes for every complaint a patient presents with in the clinic. Ex: I have a
stomach ache, a headache and diarrhea. My knee also hurts when I walk down stairs. These
extra complaints would be noted as Complaints #2, 3, and 4. If associated with the chief
complaint, example: diarrhea, it may be noted with all its attributes on the associated symptom
portion of the related complaint.
b. It also includes the past medical history, family history, allergies, lifestyle, social history, current
medications (correctly spelled), current supplement and over the counter drug use and a review
of systems. Please see Bates for details regarding professional charting the patient history.
2. Objective (O): This section includes the information you gather using your senses-what you see,
hear, smell and feel while conducting a physical examination of the patient. It is completed using
clinical language. Terms must be spelled correctly.
3. Assessment (A): The assessment is one of the most important aspects of the chart. All active
diagnoses, with a correct ICD-9 code for each, must be recorded in the assessment section. They
must correspond with the diagnoses that are recorded on the superbill.
Clinicians may consider their diagnosis likely but not certain, in which case they should precede
the stated diagnosis with an indicative term such as “working” diagnosis, “presumptive” or
“probable” diagnosis. In this event, the Assessment would also include rule/out(s) or a differential
diagnosis. For example: “Probable Diagnosis: Atypical Migraine Headache, Rule/Out increased
intra-ocular pressure.” Record your diagnostic rationale after each diagnosis or tentative diagnosis.
Every rule/out diagnosis requires a corresponding action in the treatment plan. Differential
diagnoses may or may not require action on the treatment plan. Finally, all active or resolved
diagnoses and problems are recorded and tracked on the patient’s “health data sheet,” which
appears on the left side of the front section of the patient’s chart. They are also included in the
assessment section and noted as resolved.
4. Problems: At BCNH, we follow a system that includes a problem list. It is described by Rakel
in Essentials of Family Practice. A problem is defined as “anything that requires diagnosis or
management or that interferes with quality of life as perceived by the patient. It is any physiologic,
pathologic, psychological, or social item of concern to either the patient or the physician.” Rakel
delineates further that a problem can be anatomic (hernia), physiologic (undiagnosed jaundice), a
specific diagnosis, a sign, a symptom, economic (financial stress), social (family discord),
psychiatric, a physical handicap, an abnormal lab or imaging finding, or a risk factor (personal or
family). Note that “problem” is a more inclusive term than “diagnosis.”
A diagnosis communicates the provider’s certainty of the existence of a specific disease entity. A
problem can be a diagnosis, or it can be a variety of assessments in progress, some requiring
further evaluation.
a. If the purpose of the charted visit was to follow-up on a previously listed problem from a
problem list, and the problem has resolved by inclusion in another diagnosis, or by cure or
disappearance, this should be noted in your assessment
b. Assessment: (Rationale or ddx)
Diagnoses: GERD—Rationale: secondary to suspected food intolerance and possible weak
sphincter muscle tone and reduced HCl/pepsin production
Problems: headache—ddx: a typical migraine, chronic sinus infection, eyestrain
5. Impression (I): After you indicate your active diagnoses and problems, you may then, give your
impression of the patient. Remember to write this section professionally and respectfully. Nothing
should be included in this section that you would not directly tell your patient. This includes the
naturopathic diagnosis and the principles utilized in the case.
6. Plan (P): All actions recommended or prescribed at the present patient visit must be noted in the
plan section of the patient’s chart. This will include instructions for diet or lifestyle modification or
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