Term
| What are the 6 c's of patient history and assessment? |
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Definition
1.) Client words are recorded exactly
2.) Clarity is essential when describing conditions
3.) Completeness is required
4.) Conciseness can save time nd space
5.) Chronological order
6.) Confidentiality to protect privacy. |
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Term
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Definition
| Specific pieces of information |
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Term
| What is a chief complaint? |
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Definition
| Subjective statement by the patient describing the most significant symptoms or signs |
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Term
| What is the basis for all treatment? |
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Definition
| The patient interview/history. |
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Term
| What information can be taken from a patient's interview/history? |
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Definition
Information for research
Reportable diseases
Insurance claims
Becomes a legal record so document well |
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Term
| What is the responsibility of the patient during an interview? |
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Definition
1.) provide accurate information
2.) particpate in decisions
3.) provide their advance directive
4.) inform the doctor if they anticipate problems following a treatment plan
5.) Follow the physician orders for treatment
6.) Provide healthcare agencies with necessary information for insurance claims and word with healthcare facilities to make arrangement to pay fees. |
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Term
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Definition
| Facilities may not use/disclose protected information for any purpose that is not in the privacy notice. Patient consent is REQUIRED when information is disclosed. Privacy notice must be posted. |
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Term
| What happens if HIPAA is not followed? |
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Definition
| Individual health care workers can be subject to fines up to 250,000 and 10 years in jail. |
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Term
| What are 4 skills essential for a good interview? |
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Definition
1.) Be a good listener
2.) Be aware of nonverbal clues and body language
3.) Use a broad knowledge base
4.) Summarize to form a general picture |
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Term
| What are the 7 steps for interview success? |
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Definition
1.) Do your research before interview
2.) Plan the interview
3.) Approach the patient and request interview
4.) Conduct in private
5.) Deal with sensitive topics w/ respect
6.) Do not diagnose or give diagnostic opinions
7.) Formulate general picture. |
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Term
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Definition
| Common emotional response when seeing a physician. |
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Term
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Definition
| Patient has heightened ability to observe and make connections. |
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Term
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Definition
| Patient has difficulty focusing on details, feels panicky and virtually helpless. Lack of focus will hinder your ability to get the information and cooperation needed. |
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Term
| What are some common symptoms of depression? When can depression occur? |
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Definition
- profound sadness
- fatigue
- difficulty falling asleep
- loss of appetite
- loss of energy
Occurs in late adolesence, middle age, and after retirement. |
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Term
| When should you suspect abuse? |
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Definition
| The patient speaks in a guarded way, unlikely explanation for injuries, no history of injury or history is suspicious. |
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Term
| What are some signs of child abuse? |
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Definition
-Failure to thrive
-Sever dehydration or underweight
-Delayed medical attention
-Hair loss
-Drug Use
-Genital Injuires |
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Term
| Disabilities that make an elderly person dependent can also can leave them... |
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Definition
| defenseless against abuse. |
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Term
| What are signs of drug abuse? |
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Definition
-Behave erratically, have mood changes, suffer loss of appetite, constantly tired.
-Blackouts
-Bruises/trembling hands
-Secretive & guilty about drinking |
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Term
| What are the contents of a patient's chart? |
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Definition
- Registration Form
- Patient Medical History
- Test Results
- Records from other physicians/hospitals
- Diagnosis and Treament plan
- Operative Reports
- Informed Consents
- Discharge summary and Correspondences |
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Term
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Definition
S - Subjective Data
O - Objective Data
A - Assessment
P- Plan of action |
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Term
| What does a patient's medical history include? |
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Definition
Pertinent information about the patient and the patient's family.
Age, previous illness, surgical history, allergies, medications, family medical history |
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Term
| What is the conventional/source orientated medical record? |
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Definition
| arranged according to who provided the information |
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Term
| What is the problem-oriented medical record? |
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Definition
| More extensive. Includes databases, problem list, and plans of care. |
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Term
| Computerized medical records are? |
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Definition
| Use both Source and Problem oriented. |
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Term
| A health history form usually includes? |
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Definition
-Personal data
-Chief complaint
-History of present illness
-Past Medical history
-Family History
-SOcial and occupational history
-Review of systems |
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Term
| What do we use medical records for? |
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Definition
-Care management
-Quality review
-Claim filing
-Legal interests of Parties
-Education
-Research
-Public Health
-Entrepreneurial by Providers |
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Term
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Definition
• Admission Report
o Reason for admission
• Vital Statistics
• Hospital Stay Info
• Diagnoses
• DRG Data
• Consent to Treatment Statement
• Medical History
• Physicians Orders
• Report of Physical Exam
• Progress Notes
• Pathology Reports
• Radiology Reports
• Consultation Report
• Anesthesia Record
• Operative Report
• Nurses’ Notes
• Vital Signs Graphics
• Medication Sheet
• Laboratory Report
• Physical Therapy Evaluation
• Respiratory Therapy Evaluation
• Special Reports
• Discharge Reports |
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Term
| What are 10 traps of interviewing? |
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Definition
1.) Providing false reassurance/hope
2.) Giving unwanted advice
3.) Using authority
4.) Using avoidance language
5.) Engaging in distancing
6.) Using professional jargon
7.) Using Leading or biased questions
8.) Talking too much
9.) Interrupting
10.) Using Why Questions |
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Term
| When do you use PQRSTU and what does it mean? |
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Definition
When taking symptoms.
-Provocative or Pallaitve? (what's causing it? when did it start etc.)
-Quality or Quantity (How does it look/feel/sound?)
-Region or Radiation (Where is it/spread anywhere?)
-Severity Scale
-Timing (onset)
-Understand of the patient's perception of the problem |
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Term
| Adolescants get the HEEADSSS interview for psychosocial. What does it mean> |
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Definition
HOME
EDUCATION
EMPLOYMENT
EATING
ACTIVITIES
DRUGS
SEXUALITY
SUCIDE/DEPRESSION
SAFETY |
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