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507 assessment int


phases of interview *introductory (explain, pt at ease) *working (data collection, longest) *termination (summarize, restate findings)
Health histary starts with with these 4 topics *biographical datae *source of referral *source of history *reason for seeking care/chief complaint
critical characteristics of a symptom PQRSTU where U is understand pts perception
past health laundry list includes childhood illness, immunizations, allergies, current medications, last exam dates, recent travel, military service...amongst similar
family history provides clues to genetically linked or familial diseases the usual list of heart disease, HTN, diabetes et al
family history should include same subjects on as genogram (extended blood family)
two methods for obtaining family history list and genogram
Review of Body systems - review, but you know them 1-general 2-integumentary 3-head 4-eyes 5-ears 6-nose/sinus 7-mouth/throat 8-neck 9-breast, axilla 10+ resp, CV, PV, GI, UG, sexual, musculoskelatal, neuro, hematlological, endocrine, psychiatric 8
functional assessment indicators self-esteem/concept---health practicies/beliefs---activity/exercise/leisure---sleep/rest---nutrition/tobacco/alcohol/street drugs---physical violence, SES, env hazards, occ health, saffety, rltnshps, coping/stress mgmt
when documenting summarize pertinent findings, don't use normal, record pertinent negatives, date/sign
ends with summary which is a subjective data base from which we bridge into phpysical assessment and helps develop successful plan of care
Created by: lorrelaws