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Health Assessment Test #1
History Taking and Documentation
21
Nursing
Graduate
06/11/2011

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Cards

Term
Building a history
Definition
-joint effort between patient and health care provider
-should reflect the patients perspective
-slow down
Term
Autonomy
Definition
patients need for self determination
Term
Beneficence
Definition
-do good for the patient
-advocate
-ex. finding better pain control for a patient
Term
Nonmaleficence
Definition
-do no harm
-ex. making sure guard rails are up
Term
Utilitaranism
Definition
consider appropriate use of resources
Term
Justice
Definition
-Fairness
-recognize balance between autonomy and competing interests
Term
Deontologic imperatives
Definition
be aware of tradition and culture contexts
Term
4 C's of Effective communication
Definition
Courtsey
Comfort
Connection
Confirmation
Term
To seek a connection:
Definition
1. dress professional
2. Have clear goals
3. bring back from tangents
4. have patient provide info
5. open ended questions
6. gentle guidance
Term
Ways to increase patient response
Definition
1. Facilitate -encourage pt to say more
2. Avoid jargon
3. Clarify
4. Reflect- repeat what you heard back
5. Ask open ended questions
6. Empathize
7. Confront
8. Interpret
Term
Barriers to communication
Definition
1. Curosisty
2. Anxiety
3. Silence
4. Depression
5. Crying and compassionate moments
6.Physical and emotional intimacy
7. Seduction
8.Anger
9. Avoiding the full story
10. Financial considerations
Term
Setting of the history
Definition
-comfort
-removal of barriers
-good lighting
-privacy
-relatively quiet
-clock in view
Term
Chief Complaint
Definition
-brief statement of reason for patient seeking care
-use direct quotes
Term
HPI
Definition
-History of present illness
-step by step evaluation of the circumstances that surround the primary reason for patients visit
Term
Structure of taking history
Definition
1. CC
2.HPI
3. PMH
4.Family medical history
5. Personal and social history
6. ROS
Term
What to do when approaching sensitive issues
Definition
-ensure privacy
-be direct and firm
-do not apologize
-do not preach
-use understandable language
-do not push
Term
CAGE
Definition
C- cutting down (have you been told you need to)
A-have people ANNOYED you with criticism
G- guilty feeling
E-eyeopeners (drink in the morning)
Term
CRAFFT
Definition
C-ridden in a CAR with a drunk driver
R-do you use it to RELAX
A- do you use ALONE
F-do you FORGET things while using
F-Have FAMILY/FRIENDS told you to cut down
T-Have you ever gotten in TROUBLE while using
Term
FICA
Definition
F-faith, belief, meaning
I- importance and influence
C-community
A- address/action in care
Term
Order of ROS
Definition
1. Skin, hair and nails
2.Head and neck
3.Lymph nodes
4.Chest and lungs
5. Breasts
6.Heart/Blood vessels
7.GI/diet
8.Endocrine
9. musculosketal
10.Neurological
11.Neurologic
12.Psychiatric
Term
Inventory history
Definition
touches on major points with out complete detail
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