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clinical skills 5&6

dev a medical history

exchange of information between HCW and pt that promotes physical and emotional well being therapeutic communication
gestures, postures, facial expressions that communicate nonverbally with others body language
over ___% of what is percieved is the direct result of body language and tone of voice 90
Helps convey comassion or concern when a pt is anxious or in pain touching
preparation;greeting and introduction;body;conclusion stages of the pt interview
always address adult pt by using their title and last name
at what distance should the pt interview be conducted 4-12 ft (social distance)
this type of questioning is the most effective during the pt interview open-ended
this type of questioning should be avoided except when following up on an open-ended question closed ended
using medical terminology; diagnosing; advising and offering false reassurance are examples of ineffective interview techniques
type of health history the covers the pt personal, family and social hx comprehensive medical hx
combination of the chief complaint and history of present illness episodic medical history
includes: previous health concerns, current health concerns,current medication list personal medical hx
UCD, previous medical illnesses, previous injuries, surgical procedures, and immunizations are part of past medical hx(PMH)
review of systems and chief complaint are part of current health concerns
provides detailed information about present and past health of pt family members family medical hx(FMH)
current medications should include prescriptions, OTC and supplements
drug allergies should be documented in red
refers to lifestyle questions social hx
parts of the social hx include alcohol, drugs, caffeine intake, smoking, diet, exercise,sexual practices
series of symptoms that are related to the pt chief complaint history of present illness(HPI)
a 24 hour clock is referred to as military time
closing professional signature includes first and last name with title
these items should be documented when applicable when developing the chief complaint location, amounts, color, size,pain
this part of the complaint should always be in the patients own words chief complaint (CC)
refers to period of time that pt has experienced symptoms related to the CC duration
Created by: clarevoyant1019
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