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Patient Assessment
| Question | Answer |
|---|---|
| Components of medical history | -Data base -chief complaint -past history -Family history -social history -system review |
| restatement | paraphrasing the patients statements |
| reflection | repeating the main idea of the conversation while identifying the feelings behind it |
| Clarification | summarize\simplify the speakers thoughts and feelings and resolve any confusion |
| denial | the patient completely rejects the information |
| suppression | the patient is consciously aware if the information or feeling but refuse to admit to. |
| reaction formation | the patient expresses his/her feelings as the opposite of what he or she really feels. |
| projection | the patient accuses someone else of having the feelings that he or she has |
| rationalization | the patient comes up with various explanations to justify his or her response |
| undoing | the patient tries to reserve a negative feeling by doing something that indicates the opposite feeling |
| regression | the patient reverts to an old, usually immature behavior to ventilate her or her feelings |
| sublimation | the patients redirect her negative feelings into a socially productive activity |
| POMR problem- Oriented medical record | form of documentation that introduces a logical sequence to recording the information obtained from the patient |
| Subjective data | chief complaint, in the patients own words |
| objective data | anything measurable, vital signs |
| SOMR Source Oriented medical record | most common form of record keeping |
| 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 senders nonverbal body language |
| familial | occurring in affecting/ members of the family more than would be expected by chance |
| psychosocial | pertaining to a combination of psychological and social factors |
| rapport | a relationship of harmony and accord between the patient and the healthcare professional |
| signs | objective findings determined by a clinical, such as fever, hypertension, or rash |
| symptoms | subjection complaints reported by the patient, such as pain or visual disturbances |