notes ch. 28= patient assessment
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| Biophysical | the science of applying physical laws/ theories to biologic problems.
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| Psychosocial | pertaining to a combination of psychological/ social factors
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| Cognitive | pertaining to the operation of the mind; referring to the process by which we become aware of perceiving, thinking, remembering.
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| signs | objective finding determined by a clinician such as a fever, hypertension or rash (basic sign of disease is a clinically evident indicator of a health problem.
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| Symptoms | subjective complaints reported by the Pt. such as pain or visual disturbances.
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| Health Insurance Portability and Accountability Act (HIPAA) | private portion of information/ Pt. care
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| CC=chief complaint | what brought them to the doctor office
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| Differentiated diagnosis | it is the new diagnosis that accrue after a period of time form the first diagnosis which is re-evaluated to see whether a changed has happen if so it is call differentiated diagnosis.
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| there are how many components of medical history? | 6 steps.
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| Database | the record of the PT. name, addy, date of birth, insurance information, personal data, history, physical examination/ labs finding.
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| CC | Chief complaint.
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| chief complaint | or present illness: purpose of the visit
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| PH | past history
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| Past history | or past medical history (PMH): summary of the PT. previous health. it includes dates/details regarding the PT's usual childhood diseases or major illness , surgeries, allergies accidents/ frequently used over the counter meds immunization.
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| UCD or UCHD | usual childhood disease.
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| OTC | over-the- counter
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| Family history | FH
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| family history (fh) | parents/siblings and their health if deceased cause/ age of death.
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| Social history | SH
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| SH | lifestyle/ hobbies/ occupation/ use of tobacco/ alcohol/ sleeping habits/ exercise/ diet/ last menstrual period.
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| LMP | last menstrual period.
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| systems review (sr)or reviews of systems (ROS) | these questions provide a guide to the PT's general health/ help detect conditions other than those covered under present illness (physician performs a systems review when doing the physical assessment.)
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| The social history | provides picture of the PT's health (lifestyle factors are oart of the PT. social history)
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| A PT in denial will reject health information | (different adaptive/no adaptive coping mechanisms)
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| Anxiety | can increase BP readings.
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| A symptom | is a PT's perception of health problem (different between subjective\objective information)
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| Suppression | the PT is consciously aware of the information but refuses to admit it (different adaptive/non adaption coping mechanisms0
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| Holistic care | assesses all of the PT's needs, not just the physical problems.
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| POMR | problem oriented medical record
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| POMR is what | organizes PT information for quick review. Has four basic parts.
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| what are the four basic parts of the POMR? | database, problem list, plan and progress notes.
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| what is database | (PT health history/ physical examination/ laboratory and diagnostic procedures)
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| Problem list | (PT C/O)
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| Plan | written plan for each problem identified
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| Progress notes | notes spells the acronym SOAP this portion of the POMR system is called SOAP notes or SOAPE notes when evaluation is included.
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| ROS (review of system) | is performed by the physician during the physical examination.
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| Invading personal space | is inappropriate in a professional relationship
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| privacy | allows PT the freedom to share the details of their health problem
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| Teenagers | value their privacy.
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| ROS = review of systems) | is the physicians finding during the physical examination.
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| understanding and communicating: | complete privacy is required for PT interviews.
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| Restatement involves | repeating or paraphrasing the PT. words.
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| Rapport | indicates the MA harmonious relationship with PT./ staff members.
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| Displaying empathy | using reflection help identify a Pt.'s feelings/ allows the PT to explain those feelings
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| Empathy | is accepting PT as they without judgment
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| Feedback | is an essential part of communication
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| Feedback varies | that the PT. understands the information given
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| Personal value | systems affect judgments/ interactions with others
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| therapeutic listening | displays empathy and allows the PT. to discuss their concerns
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| PT. with a functional disorder | has
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| Giving advice | can interfere with therapeutic communication
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| Reflection involves paraphrasing | the PT.'s words/identifying the feeling expressed
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| Reflection refers to | the PT.'s emotions
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| Subjective data | information provided by PT. about their health problem.
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| Subject data include | the PT.'s report of the symptoms of the disease.
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| direct questions | provide specific information
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| Linear communication | is initiated by the sender, dent via a channel to the receiver, who returns details of the message via feedback to the sender
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| Open- ended questions | allow the MA to gather more details about the PT.'s chef complaint.
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| Closed questions | ask for specific, short answers.
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| Closed questions provide | specific information about the PT. (Asian PT. may avoid eye contact.
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| Disorders of the neurologic system | include problems with speech/ balance
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| A child should be offered the chance | to make a decision only if there is able to refuse an option.
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| Therapeutic distance | is approximately an arms's length away (territorial boundaries of the person with whom you are communicating with)
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| Unwarranted reassurance | can interfere with a therapeutic relationship
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| body language | can interfere with therapeutic communication
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| Crossed arms and legs | may intimidate the PT.
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| Body language delivers | more than 90% of a message
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| Regression | is demonstrated when a PT. reverts to previous behavior.
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| Congruence | is reflected in verbal/ nonverbal messages that are the same.
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| congruence= agreement; | the state that occurs when the verbal expression of the message matches the senders nonverbal body language.
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| Clarification involves | summarizing/ seeking reinforcement of PT. information
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| Hypertension | and leg cramps are indicators of CV
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| CV | Cardiovascular disease.
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| SOAPE | documentation is used in the POMR chart
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| Pain cannot be | measured so it is a subjective assessment (complaints of pain is a subjective reports)
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| POMR | begins with a list of the PT. health problem
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| Symptoms | are PT. reported subjective findings
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| Judgmental statements | should never appear in the medical record
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| Choices should be | offered only if the PT can refuse
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| Referrals | are part of the PT. plan
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| Initial diagnosis | is a working diagnosis which is formed from the physicians first impressions of the PT. symptoms
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| Children should be included | in the therapeutic communication
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| Projection occurs when | an individual accuses another person of having feelings the individual possess
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| Duration | refers to the length of time the PT. has had the symptom
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| OTC drugs | information is recorded in the comprehensive history
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| You should never | skip lines between documentation entries
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| EMR | electronic medical records
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| Familial | occurring in or affecting members of a family more than would be expected by chance
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| Rapport | relationship of harmony/ accord between the PT and the healthcare professtional.
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