HCM 205 Module 4 Project One Example

Project One: Reading a Visit Note From Chief Complaint to Plan

[Student Name]

Southern New Hampshire University

HCM 205: Medical Terminology

Project One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Project One: Reading a Visit Note From Chief Complaint to Plan

A visit note is the official record of what happened in an appointment, and it drives much of what happens next: follow-up visits, referrals, tests, prior authorizations and bills. Administrative staff read notes every day but are rarely taught how. This project decodes a de-identified primary care note from Hillcrest Medical Group, section by section, and identifies the administrative tasks it creates.

What Notes Are For

Kuhn et al. (2015), summarizing an American College of Physicians position paper, argued that the primary purpose of clinical documentation is to support patient care and communication among clinicians, and warned that billing and regulatory requirements have made notes longer and harder to use. They recommended notes that are concise and focused on the patient's story and the clinician's reasoning. Knowing that purpose helps a reader find what matters in a long note.

The Note's Structure

The note follows the common SOAP format: subjective information from the patient, objective findings from the examination and tests, an assessment of the problems and a plan. At Hillcrest, the subjective section includes the chief complaint and history of present illness; the objective section includes vital signs and the physical exam.

Chief Complaint and History

The note opens: CC: R knee pain x 3 mo. HPI: 62 y/o F w/ HTN, T2DM, reports gradual onset R knee pain, worse w/ stairs, AM stiffness < 30 min, no trauma. Decoded, the patient's main concern is right knee pain for three months. The patient, a woman of 62, has hypertension and type 2 diabetes mellitus, and the pain began gradually, worsens on stairs and is accompanied by morning stiffness lasting under thirty minutes, with no injury. The short morning stiffness points toward osteoarthritis rather than an inflammatory arthritis.

Review of Systems and Medications

ROS: neg for fever, wt loss; + polyuria. Meds: lisinopril 20 mg daily, metformin 1000 mg BID. The review of systems is negative for fever and weight loss but positive for frequent urination. Lisinopril treats blood pressure, and metformin, taken twice daily, treats diabetes. Polyuria, frequent urination, can signal poorly controlled blood sugar, which the assessment addresses.

Examination and Results

Vitals: BP 148/92, HR 78, BMI 33. Exam: R knee crepitus, medial joint line tenderness, no effusion, ROM mildly limited. Labs: HbA1c 8.4%. Blood pressure is above goal, and body mass index is in the obese range. Crepitus is a grating sensation when the joint moves; tenderness along the inner joint line and mildly limited range of motion without fluid in the joint fit osteoarthritis. Hemoglobin A1c of 8.4% shows blood sugar above target over the past three months.

Assessment and Plan

A/P: 1. R knee OA: XR R knee 3 views; PT referral; NSAID prn. 2. HTN, uncontrolled: incr lisinopril to 40 mg; RTC 4 wk BP check. 3. T2DM, uncontrolled w/o complications: add GLP-1 RA, pending PA; DM education referral; A1c in 3 mo. The clinician diagnoses right knee osteoarthritis and orders a three-view x-ray, a physical therapy referral and an anti-inflammatory drug as needed. Blood pressure is not controlled, so the lisinopril dose doubles, with a return to clinic in four weeks. Diabetes is uncontrolled without complications, and a new medication class requires prior authorization from the insurer.

Key Terms Decoded

The table summarizes the terms and abbreviations a front-desk reader needs to understand in this note.

Table 1. Terms and Abbreviations in the Visit Note

Note. Composite de-identified note.

Abbreviations That Needed Checking

Three items in the note required a second look. The abbreviation NSAID, nonsteroidal anti-inflammatory drug, is standard, but the note did not name a specific drug, so a refill call would need clarification. GLP-1 RA names a whole family of diabetes injections rather than one product, and the prior authorization request must name the specific product the clinician chose. The phrase uncontrolled w/o complications matters for coding, because diabetes codes distinguish between hyperglycemia and complications such as kidney disease. In each case, decoding the term was only the first step; knowing what information was still missing prevented a delay.

Tasks the Note Triggers

For administrative staff, the plan is a task list. Book a blood pressure check in four weeks. Schedule the knee x-ray and send the physical therapy referral with the diagnosis. Start a prior authorization request for the new diabetes medication, attaching the A1c and medication history. Enroll the patient in diabetes education. Set a reminder for an A1c test in three months. Each task depends on reading the note correctly.

When Patients Read the Note

Patients increasingly read their notes online. Walker et al. (2019) surveyed patients with years of access to their visit notes and found that most read them, found them helpful for understanding their care and remembering plans and felt more in control, though some found notes confusing or worrying. Bell et al. (2017) found that patients who read their notes sometimes identified errors, such as wrong medications or history, that clinicians agreed were important. A front-desk representative who can decode a note can answer basic questions and route concerns about accuracy to the clinician.

What Decoding Revealed

Working through the note showed how much administrative work depends on a few lines in the plan, and how abbreviations such as PA and RTC carry specific instructions. It also showed the value of reading the whole note: the polyuria in the review of systems explained why diabetes treatment changed.

Conclusion

A visit note is dense but readable once its structure, terms and abbreviations are understood. Decoding it line by line lets administrative staff act on the plan accurately, help patients who read their notes and catch problems before they become delays or errors.

References

Bell, S. K., Mejilla, R., Anselmo, M., Darer, J. D., Elmore, J. G., Leveille, S., Ngo, L., Ralston, J. D., Delbanco, T., & Walker, J. (2017). When doctors share visit notes with patients: A study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship. BMJ Quality & Safety, 26(4), 262-270. https://doi.org/10.1136/bmjqs-2015-004697

Kuhn, T., Basch, P., Barr, M., & Yackel, T. (2015). Clinical documentation in the 21st century: Executive summary of a policy position paper from the American College of Physicians. Annals of Internal Medicine, 162(4), 301-303. https://doi.org/10.7326/M14-2128

Walker, J., Leveille, S., Bell, S., Chimowitz, H., Dong, Z., Elmore, J. G., Fernandez, L., Fossa, A., Gerard, M., Fitzgerald, P., Harcourt, K., Jackson, S., Payne, T. H., Perez, J., Shucard, H., Stametz, R., DesRoches, C., & Delbanco, T. (2019). OpenNotes after 7 years: Patient experiences with ongoing access to their clinicians' outpatient visit notes. Journal of Medical Internet Research, 21(5), Article e13876. https://doi.org/10.2196/13876