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Ch 28

vocab-Determining the patiens medical diagnosis

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 a family more than would be expected by chance
Present illness Chief complaint, written in chronologic sequence, with dates of onset
Psychosocial pertaining to a combination of psychological and social factors
Rapport A relationship of harmony and accord between the patient and the healthcare professionals
Signs Objective findings determined by a clinician, such as fever, hypertension, or rash
Symptoms subjection complaints reported by the patient, such as pain or visual disturbances
Physician's working diagnosis *Patient's history *Report of the chief complaint *Physical examination
Clinical Diagnosis *Treatment *Time Lapse *Reevaluation to see if diagnosis has changed
If the diagnosis has changed it is called? Differentiated diagnosis
Medical History *conducts medical history interv.. in a private area *Legally/ethically, patient has privacy rights *Record information EXACTLY as given. Do NOT interpret.
Access to pt's medical record permitted to? *Health care workers ( DIRECTLY involved) *Individuals specified on the HIPAA release form
HIPAA Health Insurance Portability & Accountability Act
Progress notes include? *purpose of th patient's visit (chief complaint) *vital signs *height/ weight *Pain report (1-10 scale)
Database record of patient's name, address, date of birth, insurance info, personal data, history, physical examination, initial lab findings
Chief complaint [CC] present illness, purpose of the patient's visit. Record using the patient's own words
Past history [PH] or past medical history [PMH] Summary of the patient's previous health. Dates/ details of: childhood diseases, major illnesses, surgeries, allergies, accidents, Immunizations, OTC meds (over-the-counter), prescriptions
Family history [FH] Details about parents/ sibling's health, deceased/cause/age
Social history [SH] Patient's lifestyle, hobbies, entertainment, education, job, tobacco/ alcohol/ drug use, sleep pattern, exercise, diet, menstrual period, birth control, sex life
Systems review Questions the state of health of each body system
Created by: chass



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