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Patient Assessment

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
Created by: pimpdaddyc713



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