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ch 28
notes ch. 28= patient assessment
| Term | Definition |
|---|---|
| Biophysical | the science of applying physical laws/ theories to biologic problems. |
| Psychosocial | pertaining to a combination of psychological/ social factors |
| Cognitive | pertaining to the operation of the mind; referring to the process by which we become aware of perceiving, thinking, remembering. |
| signs | objective finding determined by a clinician such as a fever, hypertension or rash (basic sign of disease is a clinically evident indicator of a health problem. |
| Symptoms | subjective complaints reported by the Pt. such as pain or visual disturbances. |
| Health Insurance Portability and Accountability Act (HIPAA) | private portion of information/ Pt. care |
| CC=chief complaint | what brought them to the doctor office |
| Differentiated diagnosis | 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. |
| there are how many components of medical history? | 6 steps. |
| Database | the record of the PT. name, addy, date of birth, insurance information, personal data, history, physical examination/ labs finding. |
| CC | Chief complaint. |
| chief complaint | or present illness: purpose of the visit |
| PH | past history |
| Past history | or past medical history (PMH): summary of the PT. previous health. it includes dates/details regarding the PT's usual childhood diseases or major illness , surgeries, allergies accidents/ frequently used over the counter meds immunization. |
| UCD or UCHD | usual childhood disease. |
| OTC | over-the- counter |
| Family history | FH |
| family history (fh) | parents/siblings and their health if deceased cause/ age of death. |
| Social history | SH |
| SH | lifestyle/ hobbies/ occupation/ use of tobacco/ alcohol/ sleeping habits/ exercise/ diet/ last menstrual period. |
| LMP | last menstrual period. |
| systems review (sr)or reviews of systems (ROS) | these questions provide a guide to the PT's general health/ help detect conditions other than those covered under present illness (physician performs a systems review when doing the physical assessment.) |
| The social history | provides picture of the PT's health (lifestyle factors are oart of the PT. social history) |
| A PT in denial will reject health information | (different adaptive/no adaptive coping mechanisms) |
| Anxiety | can increase BP readings. |
| A symptom | is a PT's perception of health problem (different between subjective\objective information) |
| Suppression | the PT is consciously aware of the information but refuses to admit it (different adaptive/non adaption coping mechanisms0 |
| Holistic care | assesses all of the PT's needs, not just the physical problems. |
| POMR | problem oriented medical record |
| POMR is what | organizes PT information for quick review. Has four basic parts. |
| what are the four basic parts of the POMR? | database, problem list, plan and progress notes. |
| what is database | (PT health history/ physical examination/ laboratory and diagnostic procedures) |
| Problem list | (PT C/O) |
| Plan | written plan for each problem identified |
| Progress notes | notes spells the acronym SOAP this portion of the POMR system is called SOAP notes or SOAPE notes when evaluation is included. |
| ROS (review of system) | is performed by the physician during the physical examination. |
| Invading personal space | is inappropriate in a professional relationship |
| privacy | allows PT the freedom to share the details of their health problem |
| Teenagers | value their privacy. |
| ROS = review of systems) | is the physicians finding during the physical examination. |
| understanding and communicating: | complete privacy is required for PT interviews. |
| Restatement involves | repeating or paraphrasing the PT. words. |
| Rapport | indicates the MA harmonious relationship with PT./ staff members. |
| Displaying empathy | using reflection help identify a Pt.'s feelings/ allows the PT to explain those feelings |
| Empathy | is accepting PT as they without judgment |
| Feedback | is an essential part of communication |
| Feedback varies | that the PT. understands the information given |
| Personal value | systems affect judgments/ interactions with others |
| therapeutic listening | displays empathy and allows the PT. to discuss their concerns |
| PT. with a functional disorder | has |
| Giving advice | can interfere with therapeutic communication |
| Reflection involves paraphrasing | the PT.'s words/identifying the feeling expressed |
| Reflection refers to | the PT.'s emotions |
| Subjective data | information provided by PT. about their health problem. |
| Subject data include | the PT.'s report of the symptoms of the disease. |
| direct questions | provide specific information |
| Linear communication | is initiated by the sender, dent via a channel to the receiver, who returns details of the message via feedback to the sender |
| Open- ended questions | allow the MA to gather more details about the PT.'s chef complaint. |
| Closed questions | ask for specific, short answers. |
| Closed questions provide | specific information about the PT. (Asian PT. may avoid eye contact. |
| Disorders of the neurologic system | include problems with speech/ balance |
| A child should be offered the chance | to make a decision only if there is able to refuse an option. |
| Therapeutic distance | is approximately an arms's length away (territorial boundaries of the person with whom you are communicating with) |
| Unwarranted reassurance | can interfere with a therapeutic relationship |
| body language | can interfere with therapeutic communication |
| Crossed arms and legs | may intimidate the PT. |
| Body language delivers | more than 90% of a message |
| Regression | is demonstrated when a PT. reverts to previous behavior. |
| Congruence | is reflected in verbal/ nonverbal messages that are the same. |
| congruence= agreement; | the state that occurs when the verbal expression of the message matches the senders nonverbal body language. |
| Clarification involves | summarizing/ seeking reinforcement of PT. information |
| Hypertension | and leg cramps are indicators of CV |
| CV | Cardiovascular disease. |
| SOAPE | documentation is used in the POMR chart |
| Pain cannot be | measured so it is a subjective assessment (complaints of pain is a subjective reports) |
| POMR | begins with a list of the PT. health problem |
| Symptoms | are PT. reported subjective findings |
| Judgmental statements | should never appear in the medical record |
| Choices should be | offered only if the PT can refuse |
| Referrals | are part of the PT. plan |
| Initial diagnosis | is a working diagnosis which is formed from the physicians first impressions of the PT. symptoms |
| Children should be included | in the therapeutic communication |
| Projection occurs when | an individual accuses another person of having feelings the individual possess |
| Duration | refers to the length of time the PT. has had the symptom |
| OTC drugs | information is recorded in the comprehensive history |
| You should never | skip lines between documentation entries |
| EMR | electronic medical records |
| Familial | occurring in or affecting members of a family more than would be expected by chance |
| Rapport | relationship of harmony/ accord between the PT and the healthcare professtional. |
Created by:
sno413
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