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clinical skills

ch 5 Conducting a Patient Interview

important uses for the medical record financial purposes; legal document;educational tool;statistical data;communication between staff; document and track patients progress
SOMR source oriented medical record
SOMR is divided into the following sections history and physical;progress notes;nursing notes;lab report; diagnostic reports
POMR problem oriented medical record
POMR contains four stages database;problem list; plan of action; progress notes
subjective; objective; assessment; plan are which types of note SOAP
data that the patient reports subjective data
information that the healthcare worker observes objective data
subjective data includes pain scale
objective data includes vital signs
doctors diagnosis is included in which portion of the soap note assessment
tests and procedures to be done and treatment for the diagnosis made can be found in which portion of the soap note plan
administrative data in the medical record includes demographics; insurance; correspondence; legal
clinical data in the medical record includes medical history; physical exam;progress notes; medication record;phone reports; education sessions;lab documents; diagnostic reports; consults; reports from other services and institutions;flow sheets
features of the EMR time efficient;better organization;communication between practices
pitfalls of the EMR cost of software;training time and costs; system goes down; risk of private information being accessed
the push for the EMR was put forth by which president and was to be instituted by what year President Bush by 2014
security measures to ensure HIPPA compliance back up files; encrypted passwords; restrict access to sites; change passwords on a regular basis
medical record rention 7-10 years
proper disposal of paper medical records is done by shredding
documentation do's correct chart; document all encounters; chart thoroughly; chart accurately; correct spelling; date and time each entry; legible;use standard abbreviations
approved closing signature on medical records includes first and last name followed by credentials
documentation dont's Don't: procrastinate;diagnosis;document for someone else; alter records; allow someone else to document for you
reason patient is being seen chief complaint
CC should be written in what the patients own words
elaborates on patients progress between visits progress note
documenting lab procedures should include type of specimen;source specimen was obtained from; test performed in house or sent out
documenting in office procedures should include name of test/procedure;where it was performed;results;who ordered the test
making corrections in a medical reocrd draw a single line through the error, your intitals; enter correction
educational sessions should be documented where in the chart progress note or educational log
refers to period of time that pt has experienced symptoms related to the CC duration
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 compassion or concern when a pt is anxious or upset touching
preparation;greeting and introduction;body;conclusion stages of the pt interview
always address adult pt by using their title and last name
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
this part of the complaint should always be in the patients own words chief complaint (CC)
questions r/t the CC such as: color;location;duration;size;associated S&S are known as HPI: history of present illness
Created by: clarevoyant1019
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