Delmar Chapters 4, 15, 18, 23, 25
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| trendelenburg | used for shock patients
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| sim's | vaginal or rectal exams; drape covers shoulders to the knees
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| prone | posterior aspect of body including back or spine and legs; drape covers mid-chest area to legs
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| knee chest | rarely used; proctologic exams and sigmoidoscopy procedures
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| fowler's | table raised 45 or 90 degrees; cardiovascular or respiratory problems
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| lithotomy | used for pelvic, proctoscopy, sigmoidoscopy exams
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| dorsal | comfortable position for patients with back and abdominal problems; can be used for urinary catheterization; teen pelvic exams; diamond shape drape
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| supine (horizontal recumbent) | exam of the anterior surface of the body; drape lap or waist down
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| manipulation | flexion and extension of joints
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| mensuration | process of measuring
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| auscultation | process of listening directly to body sounds with a stethoscope
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| percussion | process of eliciting sounds from the body by tapping
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| palpation | exam of body using touch
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| observation or inspection | general health, posture, body movements, skin, mannerisms, grooming
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| ataxia | uncoordinated wide based walk
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| bruits | abnormal sounds
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| cyanosis | slightly blue or gray discoloration of skin
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| fenestrated drape | covers patient from shoulder to knee
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| gait | manner or style of walking
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| jaundice | yellowing of skin
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| labyrinthitis | inner ear infection
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| pallor | lack of color or paleness
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| pyorrhea | discharge of pus from the gums around the teeth
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| scleroderma | a tight and atrophied skin
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| symmetry | shape and size of body parts located on opposite side of the body
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| tinnitus | ringing in the ears
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| vertigo | dizziness
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| vitiligo | white patches on the skin
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| charting rules | black or blue ink, no spaces, no erasing, first initial, last name and title, correcting errors by crossing out entry and write "Corr" above entry. Red ink can be used corrected notation
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| POMR four major components | database; problem list; diagnostic and treatment plan; progress notes
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| medical history form | present health history; personal and family health history; social history; military service; body system questionnaire; medications; ROS
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| release of information form | used to obtain medical records
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| privacy information form | notice of privacy practice required to be given to all patients. 04/2004 HIPPA limits in which individuals protected health information (PHI) could be used or disclosed
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| demographic data form | registers all the patients information which includes: DOB, SS#, insurance information, emergency contact, release of information signature
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| providers perspectives | disease and successfully managing treatments, medications and procedures to control disease problems
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| patient perspectives | the illness and management of illness
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| cross-cultural model | important to understand that every patient interview is a cross-cultural one
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| preparing for the patient | exam room is clean; all necessary supplies are available; review of patients chart - note the age
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| subjective | known by the patient but cannot be seen by provider
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| source-oriented medical record (SOMR) | traditional or conventional method of charting
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| SOAP/SOAPER | subjective data: patients own words; objective; assessment; plan of treatment; education; response
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| problem-oriented medical record (POMR) | more efficient way of keeping chart notes
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| objective | can be seen, heard or measured by an observer
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| clinical diagnosis | results with history, exam, and symtoms are determined
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| chief complaint | "CC"; the problem that brings in the patient
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| CHEDDAR | chief complaint; history; examination; details of problem; drugs and dosages; assessment; return visit
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| computerized health history | two types: patient and provider generated; if patient doesn’t want to use, a face to face option must be given; completes during or after patient interview
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| language difficulty | arrange interpreter prior to scheduling appointment
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| Refused to provide information | charted as "patient refused"
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| medical health history includes | personal data; CC; present illness - medications, allergies, other providers seen; medical history; family history; social and occupational history; ROS
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| characteristics of CC | location; radiation; quality (describs the pain); severity; associated symtoms; aggravating factors; alleviating factors; setting and timing
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| location | the place where the symptom is located
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| radiation | how large an area the symtoms covers
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| quality | characteristic of the symtoms
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| severity | level and affects of pain
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| associated symtoms | describe what other minor symtoms accompany the CC
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| aggravating and alleviating symtoms | what makes the symtoms worse and/or decrease
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| setting and timing | when the symtoms started and what happened when it started
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| allergies | need to be noted in a readily visible part of the chart; a red sticker is commonly used
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| review of systems (ROS) | performed during the physical exam and only the pertinent body systems will be reviewed
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| body systems | Â Cardiovascular, Digestive, Endocrine, Lymphatic, Muscular, Nervous, Reproductive, Respiratory, Skeletal, Integumentary (AKA skin), Urinary systems
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| medical chart | a legal document which belongs to the provider
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| continuity of care record (CCR) | developed by a number of medical groups (American Academy of Family Physicians and the American Academey of Pediatrics); improve continuity care, reduce errors, assure minimum standard that is shared with another provider
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| joint commissions journal on quality and patient safety | reports that it is best not to use abbreviations
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| chart organization | kept in chronologic order
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| insurance carriers role | check codes for procedure and diagnoses agree; coverage in force at time of service; no pre-existing condition; no exclusions or restrictions
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| follow up on claims | after a period of 4 - 6 weeks
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| common errors in completing claim forms | typographic errors, incorrect information, all blanks completed, procedure with correct diagnoses, procedure medically necessary, no staples used
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| patient must do this | sign authorization to release necessary medical information
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| pathology and laboratory | codes begin in 8
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| radiology, nuclear medicine, diagnostic ultrasound | codes begin in 7
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| surgery | codes begin in 1 - 6; divides codes according to system
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| anesthesia | codes begin in 01
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| evaluation and management | codes begin in 99; every possible combination of medical facility visit
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| five-digit code for unlisted services | the code ends in 99 and a special report must be submitted with an insurance claim form
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| CPT Manual | issued every October; with 7 sections
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| V Codes | used for anything not related to sickness or illness
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| up-coding | also known as code creep, over-coding or over billing; deliberately billed a higher rate service than what was performed
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| Uniform Bill 04 (UB-04) | a National Provider Identifier number must accommodate this form; standard form used for inpatient admissions, outpatient and emergency departments
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| unbundling codes | separating the components of a procedure and reports them as billable codes with charges to increase reimbursement rates
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| Point of Service device (POS) | electronic device
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| bundled codes | grouping of several services that are directly related to a specific procedure and paid as one
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| claim register | used to track claims filed
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| CMS-1500 (08-05) | claim form accepted by most insurance carriers
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| current procedural terminology (CPT) | developed by the American Medical Association (AMA) to convert commonly accepted descriptions of medical procedures into a five-digit numeric code
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| down-coding | performed by insurance carriers if claims are ambiguous and reimburse the provider for the lowest possible fee
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| E codes | injury or poisoning
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| encounter form | provider completes for type of procedures used at time of service. Information from this form is translated onto the claim form
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| explanation of benefits (EOB) | form sent to patient detailing charges allowed, amounts applied to deductibles, amounts not covered
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| Healthcare Common Procedures Coding System (HCPCS) | developed by Medicare in 1983 as a supplement to the CPT system
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| ICD 9 CM | developed by the WHO in 1977; classify all known diseases consisting of three-digit code with one or two numeric modifiers
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| M codes | primarily used for cancer
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| modifier | two-digit numeric number, used to provide additional information to insurance payers for procedures or services that have been altered
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| medicine | codes begin in 9; cover immunizations, injections, dialysis, allergen, immunotherapy, chemotherapy, ophthalmologic, cardiovascular, pulmonary, and neurologist procedures
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| index | comprehensive index listing every procedure alphabetically
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| ICD 9 CM - 3 volumes | Volume I - tabular list; Volume II - alphabetic listing (used first when searching for an ICD 9 code); Volume III - procedures in tabular form
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| when coding | do not guess; be precise; do not code what is not there
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| third party | the insurance carries
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| Incoming mail | directed to the appropriate personnel. Medical journals and advertisements are given to the provider; magazines and newspapers are placed in the reception area
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| four major styles of letters | full block; modified block standard; modified block indented; simplified
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| accepted form letters | thank referring providers; emphasizing patients criteria of care; announcement of new insurance; order supplies; acknowledging speaking engagement; reminder of payment due
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| notations | "c" for copy; "pc" for photocopy; "bcc" - this is only used on the copy to the individual receiving a copy without the letters recipients knowledge
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| reference initials | composer of letter in all caps; medical assistants initials in lowercase. Ex: WL:jg or WL/jg
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| styles of complimentary closure | formal, general, informal
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| complimentary closing | begins on the second line below the body of the letter
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| subject line | keyed on the second line below saluation
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| saluation | keyed flush with left margin, second line below the inside address
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| guidelines for letter placement | margins may be 1, 1.5 or 2 inches; last line should end no less than 1 inch from bottom of page;do not divide the last word;minimum of three lines should be keyed on a second page; single space within paragraphs; double space between paragraphs
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| inside address | keyed flush with left margin. *credentials appear after the providers name
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| spelling | always check with in the dictionary for the correct spelling and read the definition
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| writing tips | follow style and format set by provider; think about key points to be addressed; establish a tone of voice; use language the reader will understand; short sentences containing one idea
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| when writing | correspondence is a reflection of the medical office
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| proofreading | process of reading the document and checking for accuracy
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| proofreading tips | read each document twice; prepare document, set it aside and proofread a third time later; do not proofread when tired; long documents, proofread in short intervals; have another staff member proofread
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| date line | usually keyed on line 15 or two to three lines below the letterhead
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| full blocker letter | most time efficient in ambulatory care
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| modified block standard | all lines begin at the left margin except date line, closure, signature
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| simplified | omits salutation and closure
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| optical character readers (OCRs) | a scanner reads the zip code on the bottom line and prints a bar code in the lower right corner. Handwritten envelopes can not be read by the scanner
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| other types of correspondence | memo-randum (memo), meeting agendas, meeting minutes
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| agenda | specific items to discuss at the meeting
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| minutes | a written record of what transpired during the meeting
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| postal classes | first-class, periodical class (use to be second-class), standard mail, bulk mail, parcel post mail, media mail, priority mail, registered mail, express mail
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| Envelop common sizes | 6 3/4, 7, 10
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| steps to building trust | risk/trust, empathy, respect, genuineness, active listening
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| therapeutic communication cannot happen without | taking into consideration the cultural and religious background
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| common bias or prejudice | discrimination based on race or religion
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| common bias or prejudice | prejudice related to sexual preference
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| common bias or prejudice | choosing providers according to gender
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| common bias or prejudice | preference for western style medicine
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| touch | a powerful tool that communicates what cannot be expressed verbally
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| percentage of nonverbal communication | 70%
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| percent of the tone | 23%
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| percentage of the spoken word | 7%
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| five C's in communication | complete, clear, concise, cohesive, courteous
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| modes of communication | speaking, listening, gestures, writing
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| feedback | after the receiver has decoded the message sent
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| receiver | recipient of the sender's message and decodes the meaning of the message
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| message | the content being communicated
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| sender | encoding or creating the message to be sent
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| communication cycle | sender, message, receiver, feedback
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| undoing | actions designed to make amends or cancel out inappropriate behavior
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| time focus | attitude towards life: future, present, past
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| therapeutic communication | adds an element of empathy
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| sublimation | the channeling of a socially unacceptable behavior into a socially acceptable behavior
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| roadblocks | close communication and prevent quality care of the total person
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| repression | subconscious reaction, experiences temporary amnesia
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| regression | an attempt to withdraw from an unpleasant circumstance by retreating to an earlier, more secure stage in life
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| rationalization | the mind's way of making unacceptable behavior or events acceptable by devising a rational reason
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| projection | means of defending against feelings or urges the person does not want to admit they are experiencing
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| prejudice | an opinion or judgement that is formed before all the facts are known
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| perception | conscious awareness of one's own feelings and the feelings of others
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| open-ended questions | courages patient to provide additional information
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| active listening | listening with a third ear. Being aware of what the patient is not saying or picking up on hints to the real message
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| bias | a slant toward a particular belief
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| body language | unconscious body movements, gestures, and facial expressions
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| closed questions | answered with a simple "yes" or "no"
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| clustering | grouping nonverbal messages into statements or conclusions
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| compensation | substituting strength for a weakness
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| congruency | between verbal and nonverbal communication. Don’t send mixed messages
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| cultural brokering | the act of bridging, linking, or medicating between groups
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| culture | a pattern of many concepts, beliefs, values, habits, and skills
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| decode | interpet the meaning of the message
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| defense mechanism | behavior that is used to protect the ego from guilt, anxiety, or loss of esteem
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| denial | refusal to accept painful information
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| displacement | the subconscious transfer of unacceptable emotions, thoughts or feelings
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| encoding | creating the message to be sent
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| Abraham Maslow | considered the founder of humanistic psychology .
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| hierarchy of needs | 1. survival; 2. security; 3. love; 4. esteem; 5. self-actualization
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| high-context communication | relies on body language, reference to environmental objects, and culturally relevant phraseology to communicate an idea
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| indirect statements | elicit a response from a patient without feeling questioned
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| interview techniques | knowing how to encourage the best communication
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| kinesics | study of body language
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| low-context communication | explicit and highly detailed language. In your face
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| masking | attempt to conceal or repress the true feeling or message
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| personal space | 1 1/2 to 4 feet
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| intimate space | 1 1/2 feet to touching
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| social space | 4 to 12 feet
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| public space | 12 to 15 feet
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| facial expression | most important and observed nonverbal communication
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| posture | the manner in which we carry ourselves or pose in situations
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| finger tapping | impatience, nervousness
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