Busy. Please wait.

show password
Forgot Password?

Don't have an account?  Sign up 

Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
We do not share your email address with others. It is only used to allow you to reset your password. For details read our Privacy Policy and Terms of Service.

Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.
Don't know
remaining cards
To flip the current card, click it or press the Spacebar key.  To move the current card to one of the three colored boxes, click on the box.  You may also press the UP ARROW key to move the card to the "Know" box, the DOWN ARROW key to move the card to the "Don't know" box, or the RIGHT ARROW key to move the card to the Remaining box.  You may also click on the card displayed in any of the three boxes to bring that card back to the center.

Pass complete!

"Know" box contains:
Time elapsed:
restart all cards
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

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