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Ch 28
Patient Assessment LN
| Question | Answer |
|---|---|
| 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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