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Chapter 28

Patient Assessment study notes

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 sender's nonverbal body language
Familial Occurring in or affection members of a family more than would be expected by chance
Holistic Considering the Pt. as a whole including the physical, emotional, social, economic, and spiritual needs of the person.
Present Illness The chief compliant, written in chronology sequence with dates of onset
Psychosocial Pertaining to a combination of psychological and social factors
Rapport Relationship of Harmony and accord between the Pt. and the healthcare professional.
Signs Objective finding determined by a clinician such as a fever, rash or high BP
Symptoms Subjective complaints reported by the Pt. such as pain or visual disturbances.
When you're conducting an interview with a new Pt. you should use? The therapeutic nonverbal language to enhance the quality of the Pt. interaction. EX(establish eye contact, control over use of gestures but nod head as needed to indicate interest and empathy)
During the initial phase of the interview the MA should? Introduce themselves and state the purpose of the interview.
Database The record of the Pt. name, address, date of birth, insurance information, personal data, history physical examination and laboratory finding.
Chief Complaint (CC) or present illness The purpose of the visit
Past History (PH) or past medical history (PMH) Pt, previous health usual childhood diseases (UCD or UCHD)/ include medication and frequently used over the counter (OTC) medication
Family History (FH) detail about? Pt. parents/ siblings/ their health
Social History (SH) includes information about the Pt. lifestyle, hobbies, entertainment preferences, education, occupation, use of tobacco, alcohol, sleeping habit, sexually active Last menstrual period (LMP)
Systems review (SR) or review of systems (ROS) these question provide a guide to the? Pt. general health and help detect conditions other than those covered under the present illness.
Regression is? Demonstrated when a Pt. reverts to previous behavior
Giving advice can interfere with? therapeutic communication
The MA should always include the Pt. in? The therapeutic communication
Closed questions provide? specific information about the Pt.
Projection occurs when? An Individual accuses another person of having feelings the individual possesses
Body language delivers more than? 90% of the message
Asian Pt. may avoid eye contact because? Its apart of their cultural
Teenagers value? Privacy
Complete privacy is required for? Pt. interview
Feedback verifies that the Pt? Understands the information provided
Congruence is? Reflected in verbal and nonverbal messages that are the same
Unwarranted reassurance can interfere with? A therapeutic relationship
Reflection refers to? The Pt.'s emotions
Personal value systems affect? Judgments and interactions with others
The child should be? Included in therapeutic communication
Crossed arms and legs may? Intimidate the Pt.
The therapeutic distance is? Approximately an arm's length away
Durations refers to? The length of time the Pt. has had the symptoms
The Physician performs a? System review when doing the physical assessment
Choices should be offered only if? The Pt. can refuse
Linear communication is initiated by? The sender, sent via a channel to the receiver, who returns details of the message via feedback to the sender
Rapport indicates that the? MA has a harmonious relationship w/ Pt. and staff members
Open ended questions allow you to? Gather more details bout the Pt. chief complaint
Clarification involves? Summarizing/ seeking reinforcement of the Pt. information
Direct questions provide? Specific information
Therapeutic listening displays? Empathy and allow the pt. to discuss her concerns
Details about a wound documented in? The objective area of the progress notes
Pain cannot be? measured; it is a subjective assessment
MA should never? Skip lines between documentation entries
SOAPE documentation is used? in the POMR chart
Subjective data include the Pt. report of? The symptoms of the disease
Referral are part of? The Pt.plan
Complaints of pain are? Subjective reports
Initial diagnosis is a? Working diagnosis, which is formed from the physician's first impressions of the Pt. symptoms
Judgmental statement should never? appear in the medical record
POMR organizes what? Pt. information for quick review
A symptom is a? Pt. perception of health problem
ROS is the? Physician's findings during the physical examination
Information provided by the pt. about their health problem is known as? Subjective data
feedback is an essential part of? Communication cycle
holistic care assesses all of the Pt.'s' Needs not just the physical problem
Objective data Are the measurements and specific identifiers recorded about the Pt.'s health
Anxiety can? Increase BP readings
Pt. in denial? Rejects health information
With suppression the pt. is? consciously aware of the information but refuses to admit it
A pt. with a functional disorder has? Symptoms but no clinical evidence of disease
Disorders of the neurologic system includes? problems w/speech and balance
Hypertension and leg cramps are indicator of? CV disease
Sign of disease is a clinically evident indicator of? Health problems
Created by: chass