During my two site visits, I presented two H&Ps and one journal article. Writing H&P in an Urgent Care setting is slightly different than the H&P we learned how to write in class. It is more focused and has a legislative component to it. For example, for my post MVA patient with a mild trapezius contusion including NEXUS criteria as a reason why I deferred imaging was something that would have been a good point to make in case if I have unintentionally omitted anything that could have prompted imaging at that point. I thought of NEXUS criteria when I was evaluating the patient and it was guiding my thought process but I did not document it.
For my next H&P, a patient with chest pain, I documented that he was low risk for pulmonary embolism according to PERC Rule so D-Dimer was not indicated at the time. However, I did not elaborate what exactly PERC Rule was, which, again, would have been a good point to document in case my H&P gets reviewed in court.
Moving on, I will document the criteria that I am currently looking up at MD Calc that guide my clinical thinking in order to protect myself legislatively, as well as patient education on concerning signs that should prompt them seek immediate help.
As per my article presentation, I chose acupuncture for migraines. I received good feedback on the presentation and the choice of the article but the one thing my preceptor pointed out that in the study the actual acupuncture was given by multiple practitioners and that it would have been a stronger study has all procedures been done by the same person.