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MAS 122
Ch.32 Med Hx & Pt Screening
| Question | Answer |
|---|---|
| What is the purpose of screening? | -Phone call or in-person(priv room) -Prioritizes the conditions of the injured following a disaster |
| How do you elicit different aspects of the chief medical complaint from the pt? | -Watch the pt's body lang (nonverbal) -Use open-ended Q's -Focus on the interview -Conclude the screening portion w/ summary |
| What is the purpose of obtaining a health Hx? | -The basis for all treatment given by provider -A guide for future treatment of the pt -Can provide statistical data |
| What is the difference between the components of the health Hx | Chief Complain: The reason a pt is seeking care, use the pt's lang., include S/O data. Present Illness & Hx of present illness: HPI Past Hx/ PMH: All issues, surgeries, illnesses, etc, current meds, any known allergies Fam Hx: Age & health status |
| How are the systems of review obtained and documented? | -Review all info from omission and clarity -Be thoroughly familiar w/ the form -Be prepared to answer Q's -Both the pt & person reviewing the form must sign it |
| Chief Complaint | The reason for the pt's visit based on S/O data |
| SOAP Method | Used for documentation: Subjective, Objective, Assessment, Plan |
| Pressent Illness (PI) | Detailed account of the current health issue, including onset, actions taken, TX, and effectiveness |
| Review of Sys (ROS) | A sys review of all body sys. performed by the provide to check for abnormalities and establish baseline data |
| What are the setting requirements to In-person screening? | -Private Area -Exam Room -Importance: foundation of the pt's visit & helps in understanding their health concerns |
| What is the difference between screening & Triage? | Screening: DOB, Name, Ask what their concerns are, direct them to the right person (in person = physician) Triage: Medical emergency context *Can be used interchangeably |
| Explain the 2 types of Visits | -First Visit: extensive Q's necessary i the pt present multiple symp. or complaints -Follow Up: Assess progress/changes since the last visit, helps determine treatment effectiveness |
| What are the different techniques to ensure pt understanding? | Reflection: Paraphrasing & restating feelings & words Restatement: Briefly repeat the exact info Clarification: stating back the essential meaning as understood by you |
| Explain in your own words how the MA would. conclude the screening? | Summarize the CC and + concerns in order of importance, confirm w/ pt that the summary is accurate & reflects their concerns |
| Personal Identifiable Info (PII) | Names, addresses, phone #, SSN |
| Health info | Med Hx: details about past & current med conditions & treatment Diag info: test results, imaging, & diagnosing Treatment plans: Info regarding prescribed tx, meds, & therapy |
| Name the different Confidentiality Practices: | Physical Security :papers Digital Security: passwords Access Controls: Authorized personnel only, Need-to-know basis Data Disposal: Shredding Docs, Secure deletion |
| Revocation | Pt's have the right to w/draw consent at anytime, and such changes be promptly recorded |
| Aggravating & Alleviating Factors | Ask what worsens the pain |
| Timing & Setting | Establish info of the symptom, and what surrounds it's appearance and how it has progressed |
| Oucher Pain Scale | Numeric and facial expression to help determine pain in the pediatrics. |
Created by:
MACC2025
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