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Patient Assessment
Question | Answer |
---|---|
Components of medical history | -Data base -chief complaint -past history -Family history -social history -system review |
restatement | paraphrasing the patients statements |
reflection | repeating the main idea of the conversation while identifying the feelings behind it |
Clarification | summarize\simplify the speakers thoughts and feelings and resolve any confusion |
denial | the patient completely rejects the information |
suppression | the patient is consciously aware if the information or feeling but refuse to admit to. |
reaction formation | the patient expresses his/her feelings as the opposite of what he or she really feels. |
projection | the patient accuses someone else of having the feelings that he or she has |
rationalization | the patient comes up with various explanations to justify his or her response |
undoing | the patient tries to reserve a negative feeling by doing something that indicates the opposite feeling |
regression | the patient reverts to an old, usually immature behavior to ventilate her or her feelings |
sublimation | the patients redirect her negative feelings into a socially productive activity |
POMR problem- Oriented medical record | form of documentation that introduces a logical sequence to recording the information obtained from the patient |
Subjective data | chief complaint, in the patients own words |
objective data | anything measurable, vital signs |
SOMR Source Oriented medical record | most common form of record keeping |
biophysical | the science of applying physical laws and theories to biologic problems |
cognitive | pertaining to the operation of the mind referring to the process by which we become aware of perceiving, thinking and remembering |
congruence | agreement the state that occurs when the verbal expression of the message matches the senders nonverbal body language |
familial | occurring in affecting/ members of the family more than would be expected by chance |
psychosocial | pertaining to a combination of psychological and social factors |
rapport | a relationship of harmony and accord between the patient and the healthcare professional |
signs | objective findings determined by a clinical, such as fever, hypertension, or rash |
symptoms | subjection complaints reported by the patient, such as pain or visual disturbances |