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Ch 28

Patient Assessment LN

The science of applying physical laws/ theories to biologic problems Biophysical
pertaining to a combination of psychological/ social factors Psychosocial
pertaining to the operation of the mind; referring to the process by which we become aware of perceiving thinking/ remembering Cognitive
objective finding determined by a clinically evident indictor of a health problem Signs
subjective complaints reported by the Pt. such as pain or visual disturbances. Symptoms
Private portion of information/ Pt. care Health Insurance Portability Accountability Act (HIPPA)
What brought them to the doctor office CC (chief complaint)
It is the new diagnosis that accrue after a period of time form the first diagnosis which is re-evaluated to see whether a changed has happen if so it is call differentiated diagnosis.. Differentiated Diagnosis
The record of the PT. name, address, date of birth, insurance information, personal data, history, physical examination/laboratory findings Database
present illness: purpose of the visit Chief complaint (CC)
Past medical history (PMH): summary of the PT. previous health. It include dates/ details regarding the PT.'s usual childhood diseases (UCD) or (UCHD) major illnesses, surgeries, allergies accidents/frequently used OTC medication/immunization record Past history (PH)
parents/siblings/ and their health, if deceased, cause/ age of death. Family History (FH)
lifestyle, hobbies, occupation, use of tobacco, alcohol, sleeping habits, exercise, diet/ last menstrual period (LMP) Social History (SH)
review of systems (ROS); these questions provide a guide to the PT's general health/ help detect conditions other than those covered under present illnes System Review (SR)
Provides a holistic picture of the Pt.'s health The social history
can increase BP readings anxiety
Pt's perception of health problem A symptom
the Pt's is consciously aware of the information but refuses to admit it Suppression
assesses all of the Pt.'s needs, not just the physical problems Holistic care
Organizes Pt information for quick review, Has four basic parts POMR (problem oriented medical record)
Performed by the physician during the physical examination Review of System
allows Pt. the freedom to share the details of their health problem (teenagers value their privacy Privacy
complete privacy is required for Pt. interviews
repeating or paraphrasing the PT. words Restatement involves
indicates the MA has harmonious relationship with PT./ staff members Rapport
using reflection help identify a Pt.'s feelings/ allow the PT to explain those feelings Displaying Empathy
is accepting PT as they are, without judgment Empathy
is an essential part of communication, verifies that the Pt. understands the information given Feedback
displays empathy/ allows the PT. to discuss their concerns. PT. wit functional disorder has symptoms but no clinical evidence of a disease giving advice can interfere with therapeutic communication Therapeutic listening
The PT's words/identifying the feeling expressed Reflection involves paraphrasing
information provided by PT about their health problem (subjective data include the PT's report of the symptoms of the disease Subjective data
Provide specific information Direct questions
is initiated by the sender, sent via a channel to the receiver, who returns details of the message via feedback to the sender Linear communication
Allow the MA to gather more details about the PT''s chief complaint Open-ended questions
ask for specific, short answers. (closed questions provide specific information about the PT) (Asian PT. may avoid eye contact) Closed questions
approximately an arm's length away (territorial boundaries of the person with whom you are communicating with) Therapeutic distance
can interfere with therapeutic communication (crossed arms and legs may intimidate the pt) Body language
Delivers more than 90% of a message Body language 2
is a demonstrated when a Pt. reverts to previous behavior. congruence is a reflected in verbal/ nonverbal messages that are the same Congruence = agreement
summarizing/seeking reinforcement of PT. information. Clarification involves
indicators of CV (cardiovascular)=disease Hypertension and leg cramps
documentation is used in the POMR chart SOAPE
should never appear in the medical record Judgmental statements
are part of the PT. plan Referrals
a working diagnosis which is formed from the physician's first impressions of the PT symptoms Initial diagnosis
occurs when an individual accuses another person of having feelings the individual possesses projection
refers to the length of time the Pt. has had the symptoms duration
EMR Electronic Medical Record
occurring in or affecting members of a family more than would be expected by chance Familial
Relationship of harmony/ accord between the Pt./ the healthcare professional Rapport
Created by: chass



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