Patient Assessment study notes
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| Biophysical | The science of applying physical laws and theories to biologic problems.
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| Cognitive | Pertaining to the operation of the mind; referring to the process by which we become aware of perceiving, thinking, and remembering.
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| Congruence | Agreement; the state that occurs when the verbal expression of the message matches the sender's nonverbal body language
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| Familial | Occurring in or affection members of a family more than would be expected by chance
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| Holistic | Considering the Pt. as a whole including the physical, emotional, social, economic, and spiritual needs of the person.
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| Present Illness | The chief compliant, written in chronology sequence with dates of onset
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| Psychosocial | Pertaining to a combination of psychological and social factors
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| Rapport | Relationship of Harmony and accord between the Pt. and the healthcare professional.
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| Signs | Objective finding determined by a clinician such as a fever, rash or high BP
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| Symptoms | Subjective complaints reported by the Pt. such as pain or visual disturbances.
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| 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)
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| During the initial phase of the interview the MA should? | Introduce themselves and state the purpose of the interview.
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| Database | The record of the Pt. name, address, date of birth, insurance information, personal data, history physical examination and laboratory finding.
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| Chief Complaint (CC) or present illness | The purpose of the visit
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| 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
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| Family History (FH) detail about? | Pt. parents/ siblings/ their health
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| 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)
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| 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.
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| Regression is? | Demonstrated when a Pt. reverts to previous behavior
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| Giving advice can interfere with? | therapeutic communication
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| The MA should always include the Pt. in? | The therapeutic communication
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| Closed questions provide? | specific information about the Pt.
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| Projection occurs when? | An Individual accuses another person of having feelings the individual possesses
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| Body language delivers more than? | 90% of the message
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| Asian Pt. may avoid eye contact because? | Its apart of their cultural
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| Teenagers value? | Privacy
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| Complete privacy is required for? | Pt. interview
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| Feedback verifies that the Pt? | Understands the information provided
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| Congruence is? | Reflected in verbal and nonverbal messages that are the same
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| Unwarranted reassurance can interfere with? | A therapeutic relationship
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| Reflection refers to? | The Pt.'s emotions
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| Personal value systems affect? | Judgments and interactions with others
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| The child should be? | Included in therapeutic communication
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| Crossed arms and legs may? | Intimidate the Pt.
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| The therapeutic distance is? | Approximately an arm's length away
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| Durations refers to? | The length of time the Pt. has had the symptoms
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| The Physician performs a? | System review when doing the physical assessment
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| Choices should be offered only if? | The Pt. can refuse
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| 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
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| Rapport indicates that the? | MA has a harmonious relationship w/ Pt. and staff members
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| Open ended questions allow you to? | Gather more details bout the Pt. chief complaint
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| Clarification involves? | Summarizing/ seeking reinforcement of the Pt. information
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| Direct questions provide? | Specific information
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| Therapeutic listening displays? | Empathy and allow the pt. to discuss her concerns
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| Details about a wound documented in? | The objective area of the progress notes
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| Pain cannot be? | measured; it is a subjective assessment
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| MA should never? | Skip lines between documentation entries
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| SOAPE documentation is used? | in the POMR chart
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| Subjective data include the Pt. report of? | The symptoms of the disease
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| Referral are part of? | The Pt.plan
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| Complaints of pain are? | Subjective reports
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| Initial diagnosis is a? | Working diagnosis, which is formed from the physician's first impressions of the Pt. symptoms
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| Judgmental statement should never? | appear in the medical record
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| POMR organizes what? | Pt. information for quick review
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| A symptom is a? | Pt. perception of health problem
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| ROS is the? | Physician's findings during the physical examination
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| Information provided by the pt. about their health problem is known as? | Subjective data
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| feedback is an essential part of? | Communication cycle
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| holistic care assesses all of the Pt.'s' | Needs not just the physical problem
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| Objective data | Are the measurements and specific identifiers recorded about the Pt.'s health
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| Anxiety can? | Increase BP readings
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| Pt. in denial? | Rejects health information
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| With suppression the pt. is? | consciously aware of the information but refuses to admit it
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| A pt. with a functional disorder has? | Symptoms but no clinical evidence of disease
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| Disorders of the neurologic system includes? | problems w/speech and balance
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| Hypertension and leg cramps are indicator of? | CV disease
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| Sign of disease is a clinically evident indicator of? | Health problems
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Created by:
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