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Ch 28
vocab-Determining the patiens medical diagnosis
| Question | Answer |
|---|---|
| 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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