Patient Assessment LN
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
|
|
||||
|---|---|---|---|---|---|
| The science of applying physical laws/ theories to biologic problems | Biophysical
🗑
|
||||
| pertaining to a combination of psychological/ social factors | Psychosocial
🗑
|
||||
| pertaining to the operation of the mind; referring to the process by which we become aware of perceiving thinking/ remembering | Cognitive
🗑
|
||||
| objective finding determined by a clinically evident indictor of a health problem | Signs
🗑
|
||||
| subjective complaints reported by the Pt. such as pain or visual disturbances. | Symptoms
🗑
|
||||
| Private portion of information/ Pt. care | Health Insurance Portability Accountability Act (HIPPA)
🗑
|
||||
| What brought them to the doctor office | CC (chief complaint)
🗑
|
||||
| It is the new diagnosis that accrue after a period of time form the first diagnosis which is re-evaluated to see whether a changed has happen if so it is call differentiated diagnosis.. | Differentiated Diagnosis
🗑
|
||||
| The record of the PT. name, address, date of birth, insurance information, personal data, history, physical examination/laboratory findings | Database
🗑
|
||||
| present illness: purpose of the visit | Chief complaint (CC)
🗑
|
||||
| Past medical history (PMH): summary of the PT. previous health. It include dates/ details regarding the PT.'s usual childhood diseases (UCD) or (UCHD) major illnesses, surgeries, allergies accidents/frequently used OTC medication/immunization record | Past history (PH)
🗑
|
||||
| parents/siblings/ and their health, if deceased, cause/ age of death. | Family History (FH)
🗑
|
||||
| lifestyle, hobbies, occupation, use of tobacco, alcohol, sleeping habits, exercise, diet/ last menstrual period (LMP) | Social History (SH)
🗑
|
||||
| review of systems (ROS); these questions provide a guide to the PT's general health/ help detect conditions other than those covered under present illnes | System Review (SR)
🗑
|
||||
| Provides a holistic picture of the Pt.'s health | The social history
🗑
|
||||
| can increase BP readings | anxiety
🗑
|
||||
| Pt's perception of health problem | A symptom
🗑
|
||||
| the Pt's is consciously aware of the information but refuses to admit it | Suppression
🗑
|
||||
| assesses all of the Pt.'s needs, not just the physical problems | Holistic care
🗑
|
||||
| Organizes Pt information for quick review, Has four basic parts | POMR (problem oriented medical record)
🗑
|
||||
| Performed by the physician during the physical examination | Review of System
🗑
|
||||
| allows Pt. the freedom to share the details of their health problem (teenagers value their privacy | Privacy
🗑
|
||||
| complete privacy is required for | Pt. interviews
🗑
|
||||
| repeating or paraphrasing the PT. words | Restatement involves
🗑
|
||||
| indicates the MA has harmonious relationship with PT./ staff members | Rapport
🗑
|
||||
| using reflection help identify a Pt.'s feelings/ allow the PT to explain those feelings | Displaying Empathy
🗑
|
||||
| is accepting PT as they are, without judgment | Empathy
🗑
|
||||
| is an essential part of communication, verifies that the Pt. understands the information given | Feedback
🗑
|
||||
| displays empathy/ allows the PT. to discuss their concerns. PT. wit functional disorder has symptoms but no clinical evidence of a disease giving advice can interfere with therapeutic communication | Therapeutic listening
🗑
|
||||
| The PT's words/identifying the feeling expressed | Reflection involves paraphrasing
🗑
|
||||
| information provided by PT about their health problem (subjective data include the PT's report of the symptoms of the disease | Subjective data
🗑
|
||||
| Provide specific information | Direct questions
🗑
|
||||
| is initiated by the sender, sent via a channel to the receiver, who returns details of the message via feedback to the sender | Linear communication
🗑
|
||||
| Allow the MA to gather more details about the PT''s chief complaint | Open-ended questions
🗑
|
||||
| ask for specific, short answers. (closed questions provide specific information about the PT) (Asian PT. may avoid eye contact) | Closed questions
🗑
|
||||
| approximately an arm's length away (territorial boundaries of the person with whom you are communicating with) | Therapeutic distance
🗑
|
||||
| can interfere with therapeutic communication (crossed arms and legs may intimidate the pt) | Body language
🗑
|
||||
| Delivers more than 90% of a message | Body language 2
🗑
|
||||
| is a demonstrated when a Pt. reverts to previous behavior. congruence is a reflected in verbal/ nonverbal messages that are the same | Congruence = agreement
🗑
|
||||
| summarizing/seeking reinforcement of PT. information. | Clarification involves
🗑
|
||||
| indicators of CV (cardiovascular)=disease | Hypertension and leg cramps
🗑
|
||||
| documentation is used in the POMR chart | SOAPE
🗑
|
||||
| should never appear in the medical record | Judgmental statements
🗑
|
||||
| are part of the PT. plan | Referrals
🗑
|
||||
| a working diagnosis which is formed from the physician's first impressions of the PT symptoms | Initial diagnosis
🗑
|
||||
| occurs when an individual accuses another person of having feelings the individual possesses | projection
🗑
|
||||
| refers to the length of time the Pt. has had the symptoms | duration
🗑
|
||||
| EMR | Electronic Medical Record
🗑
|
||||
| occurring in or affecting members of a family more than would be expected by chance | Familial
🗑
|
||||
| Relationship of harmony/ accord between the Pt./ the healthcare professional | Rapport
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
chass
Popular Medical sets