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MED158 Chapter 36
| Question | Answer |
|---|---|
| Restatement | Repeating what the patient says in your own words. |
| Subjective Data | Thoughts, Feeling, and perceptions, including Chief Complaint (CC) |
| Objective Data | Readily apparent and measurable information, such as test results |
| Verbalizing | Stating what you believe the patient is suggesting |
| First step in the Exam Process | Patient Interview |
| Patient Interview | Well-conducted initial interview in the exam room |
| A Well-conducted Patient Interview helps | Establish a beneficial relationship between you and the patient |
| A Well-conducted Patient Interview can Provide | A detailed exchange of pertinent information |
| Patient Rights | Expecting reasonable continuity of care and being assured of confidentiality |
| Improper Language Skills or Sloppy Body Language can give the patient the perception that you are | Unintelligent & Uneducated |
| To conduct a successful patient interview and obtain Hx and Health Information, you need to apply a variety of | Skills |
| Chief Complaint(CC) | Subjective statement made by the patient describing the patient's most significant symptoms or signs of illness |
| Mirroring | Restating what the patient says |
| Reflection | Thought or idea formed as a result of a deeper thought |
| Clarification | Encouraging the patient to provide additional information |
| 1st step to conduct a successful interview | Do your research before thee patient interview |
| 2nd step to conduct a successful interview | Plan the interview |
| 3rd step to conduct a successful interview | Approach the patient and request the interview |
| 4th step to conduct a successful interview | Make the patient feel at ease |
| 5th step to conduct a successful interview | Conduct the interview in private without interruptions |
| 6th step to conduct a successful interview | Deal with sensitive topics with respect |
| 7th step to conduct a successful interview | Do not diagnose or give a diagnostic opinion |
| 8th step to conduct a successful interview | Formulate the general picture |
| How many steps in conducting a successful interview | 8 |
| Pt with mild anxiety may have a heightened ability to | Observe and Make Connections |
| Patients have the right to | Receive considerate and respectful care, Refuse treatment to the extent permitted by law, Know the immediate and long-term costs of treatment choices. |
| Depression seems to occur most frequently during | Retirement & Late Adolescence |
| Signs of possible child abuse include | Genital Injuries, Being Underweight, Failure to Thrive |
| Skills needed to conduct a Successful Patient Interview | Summarizing to form a general picture, Using a broad knowledge base, Listening effectively |
| Reasons a victim will stay in a abusive relationship | Isolation, Financial Dependence, Fear of the abuser |
| Alternating Euphoria and Apprehension and an intense craving for more of the drug are symptoms of abuse of | Cocaine |
| Pt Who has difficulty focusing on details, feels panicky, and is virtually helpless has | Severe Anxiety |
| PHI that goes on a registration form | Name, Address, Insurance, Marital Status |
| Depression in middle age is often triggered by | Life Events |
| SOMR | Source-Oriented Medical Record |
| Source-Oriented Medical Record (SOMR) | Patient information is arranged based on the provider supplying the information, Patient's words, PCP, Specialist, Laboratory, and hospital |
| POMR | Problem-Oriented Medical Record Large facilities |
| Problem-Oriented Medical Record (POMR) | Patient information includes a database of patient's past medical history, Problem List, Educational, Diagnostic, treatment plan and progress notes |
| SOAPE | Subjective, Objective, Assessment, Plan, Education |
| Subjective | Information from the patient. Includes the Chief Complaint(CC) |
| Objective | Information from the practitioner's own observation or test, examinations, and test results |
| Assessment | What was assessed regarding the patient's problem |
| Plan | Treatment options, Treatment chosen, Medications, Tests, patient education and follow-up |
| What Method is used more extensively by large clinics | Problem-Oriented Medical Record (POMR) |
| Individuals more likely to be abused | Children, Elderly & Women |
| Instead of using the abbreviation A.S. Write out | Left Ear |
| Women are at greater risk for abuse during the ages of | 20-24 years old |
| Good Interview Technique | PQRST Technique |
| Side effects of Ecstasy | Confusion, Depression, Anxiety, Paranoia, Increased heart rat |
| 1st guideline to consider when using progress notes | It must be arranged in reverse chronological order |
| 2nd guideline to consider when using progress notes | Every entry must be initialed & signed by the person making the entry (VDavidson CCMA) |
| 3rd guideline to consider when using progress notes | Most common Entries made on progress notes |
| Most common Entries made on progress notes | Refills, Follow-ups, Telephone conversations, Cancellations, no-shows, referrals and consultation efforts |
| 4th guideline to consider when using progress notes | Pt name must be on note W/ Birth Date or Chart # |
| 5th guideline to consider when using progress notes | All must be dated usually has the time & date |
| Patient registration form carries the date of the encounter and list | Age, Ethnicity, Education |
| Medical form for patient remarks then doctor's comments | SOMR |
| Taking many medications | Polypharmacy |
| Rational for filing progress notes in chronological order | To ensure that the most current patient information is reviewed |
| Occupational history includes | Level of stress and exposure to hazardous substances |
| Rationale for asking children various types of questions | To allow children to feel that their points of view are important |
| Computerized medical records method uses a combination of | SOMR & POMR |
| Step 1 of Obtaining a Medical History | Wash your hands |
| Step 2 of Obtaining a Medical History | Assemble the necessary materials, Review medical history form and plan your interview |
| Step 2 of Obtaining a Medical History Rationale | Saves time and improves the effectiveness of the visit; plus, it will assist in determining the appropriate questions to ask |
| Step 3 of Obtaining a Medical History | Invite the patient to a private exam room, correctly identify the Pt by introducing yourself and asking their name and date of birth |
| Step 4 of Obtaining a Medical History | Explain the medical history form while maintaining eye contact. Make the patient feel at ease. |
| Step 5 of Obtaining a Medical History | Using language the Pt can understand, ask appropriate, open-ended questions regarding medical history form. |
| Responses for Step 5 of Obtaining a Medical History | Reflection, Restatement & Clarification |
| Step 6 of Obtaining a Medical History | Accurately document the patient's responses |
| Step 7 of Obtaining a Medical History | Thank Pt for the interview, Offer to answer any questions |
| Step 8 of Obtaining a Medical History | Sign/initial the Medical History form and file it in the Pt chart |
| Step 9 of Obtaining a Medical History | Inform the Physician/Doctor that you are finished with the medical history |
| Step 10 of Obtaining a Medical History | Wash your hands |
| A Problem-Oriented Medical Record (POMR) has | 4 Components |
| 4 Components of POMR | Database, Problem list, Initial plan, Progress notes |
| A Problem-Oriented Medical Record (POMR) has | 4 Components |
| Progress notes | ongoing documentation of patient care (often using SOAP format) |
| 4 Components of POMR | Database, Problem list, Initial plan, Progress notes |
| Progress notes | ongoing documentation of patient care (often using SOAP format) |
| Initial plan | diagnostic, therapeutic, and patient education plans |
| Problem list | list of the patient’s health problems |
| Database | patient history and exam information |
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