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ch 28

notes ch. 28= patient assessment

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