Patient Assessment
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Components of medical history | -Data base
-chief complaint
-past history
-Family history
-social history
-system review
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| restatement | paraphrasing the patients statements
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| reflection | repeating the main idea of the conversation while identifying the feelings behind it
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| Clarification | summarize\simplify the speakers thoughts and feelings and resolve any confusion
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| denial | the patient completely rejects the information
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| suppression | the patient is consciously aware if the information or feeling but refuse to admit to.
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| reaction formation | the patient expresses his/her feelings as the opposite of what he or she really feels.
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| projection | the patient accuses someone else of having the feelings that he or she has
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| rationalization | the patient comes up with various explanations to justify his or her response
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| undoing | the patient tries to reserve a negative feeling by doing something that indicates the opposite feeling
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| regression | the patient reverts to an old, usually immature behavior to ventilate her or her feelings
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| sublimation | the patients redirect her negative feelings into a socially productive activity
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| POMR problem- Oriented medical record | form of documentation that introduces a logical sequence to recording the information obtained from the patient
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| Subjective data | chief complaint, in the patients own words
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| objective data | anything measurable, vital signs
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| SOMR Source Oriented medical record | most common form of record keeping
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| biophysical | the science of applying physical laws and theories to biologic problems
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| cognitive | pertaining to the operation of the mind referring to the process by which we become aware of perceiving, thinking and remembering
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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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| familial | occurring in affecting/ members of the family more than would be expected by chance
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| psychosocial | pertaining to a combination of psychological and social factors
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| rapport | a relationship of harmony and accord between the patient and the healthcare professional
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| signs | objective findings determined by a clinical, such as fever, hypertension, or rash
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| symptoms | subjection complaints reported by the patient, such as pain or visual disturbances
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You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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