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CI1 > History Taking & Medical Documentation > Flashcards

History Taking & Medical Documentation Flashcards

1
Q

What are the goals of the patient assessment?

A
  • Define the patient’s problems accurately

- Perform an analysis on a subjective & objective assessment (signs/symptoms)

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2
Q

What is the difference between subjective and objective assessments?

A

Subjective:

  • Patient’s perspective
  • How do they feel
  • Symptoms they can describe

Objective:

  • Examiner’s perspective
  • What can you measure/observe
  • These are signs, not symptoms
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3
Q

What are the 5 parts of the Problem Oriented Medical System (POMS)?

A
  • Database (medical record)
  • Problem list
  • Initial plan (goals)
  • Progress notes
  • Discharge summary
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4
Q

What is the process for conducting an initial assessment?

A
  • Receive referral
  • Read patient’s file
  • Discuss with medical and/or nursing staff
  • Introduce yourself to patient
  • Share understanding of the story so far
  • Fill in the history gaps & physio-specific data
  • Observe patient while taking history
  • Perform physical assessment
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5
Q

What are the key bits of information in the patient’s file?

A
  • Personal details (name, where the live)
  • Assessment/progress notes
  • Anaesthetic & operation reports
  • Consultation notes (e.g. medical rounds, APS) - what is the medical plan?
  • Other records (spirometry results, biochemistry, chest x-ray etc)
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6
Q

What is the APS?

A

Acute pain service, manage surgical patients’ pain levels

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7
Q 
What do the following abbreviations mean?
TKR
HTN
NKDA
Aim D/C in 2/7
A

TKR: Total knee replacement
HTN: Hypertension
NKDA: No known drug allergies
Aim D/C in 2/7: Aiming for discharge in 2 days

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8
Q

What are the key components of the bedside chart?

A
  • Observations
  • Medications
  • Nursing care plan
  • Fluid balance chart
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9
Q

What are some key elements of taking a patient history?

A
  • Professional & conservative
  • Build rapport
  • Explain your understanding of their story
  • Ask questions to fill in the gaps
  • Record patient’s own words
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10
Q

What is the structure of the subjective assessment?

A
  • History of presenting illness (HPI)
  • Past medical history (PMH)
  • Social history (SHx)
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11
Q

What are some of the cardio-specific questions regarding symptoms (HPI)?

A
  • Time course of current symptoms
  • Mode of onset/pattern
  • Site/radiation of pain
  • Character
  • Severity
  • Aggravating/easing factors
  • Associated symptoms
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12
Q

What are symptoms?

A
  • Something that someone complains about
  • Perceptible change in the body/function
  • Only perceptible to the patient
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13
Q

What can be both a symptom and a sign?

A

Wheezes

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14
Q

What is dyspnoea?

A
  • Breathlessness associated with distress
  • Awareness of increased respiratory effort
  • Unpleasant, inappropriate
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15
Q

What is the theory of dyspnoea?

A

It’s a result of a mismatch between central respiratory motor output and incoming afferent info from receptors in airways, lungs, chest wall structures

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16
Q

What is the relationship between dyspnoea and respiratory muscles?

A

Frequently occurs when there is an increased burden on the respiratory muscles or when they have become weak

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17
Q

What are the mechanisms of dyspnoea?

A
  • Added load on mechanics of breathing (altered compliance - hyperinflation or altered airway resistance)
  • Respiratory muscle weakness
  • CV deconditioning
  • Psychological factors
18
Q

What do the following abbreviations mean?
SOB
SOBOE
PND

A

SOB: Shortness of breath
SOBOE: Shortness of breath on exertion
PND: Paroxysmal nocturnal dyspnoea (breathlessness only at night, usually after lying flat)

19
Q

What are the primary and secondary reasons for decreased exercise tolerance?

A

Primary: Due to disease process (e.g. breathlessness/fatigue)

Secondary: Due to inability to exercise causing reduction in fitness

20
Q

What are some of the questions concerning exercise tolerance?

A
  • Normal PA levels versus now
  • What type of activities cause problems?
  • Distances achieved (on flat, on stairs)
  • What subjectively limits exercise?
21
Q

What is important to exclude when considering chest pain?

A

Pain of cardiac origin

22
Q

What are some of the causes of chest pain?

A
  • Pulmonary embolism (PE)
  • Angina
  • Trauma
  • Surgery
  • Pneumonia, pleural effusion, pneumothorax
  • Musculoskeletal
23
Q

What are some types of arrhythmias?

A

Arrhythmias (without rhythm)

  • Atrial fibrillation (AF)
  • Ventricular ectopic beats (VEB)
24
Q

When is cough needed?

A
  • When mucociliary clearance is non-effective or there is an increased amount of sputum (reflex, protective mechanism)
  • When stimulated by allergens
25
Q

What may persistent cough be indicative of?

A
  • Respiratory disease
  • Secondary to medications (e.g. ACE inhibitors)
  • Post-nasal drip or reflux
26
Q

What is an important question to ask a patient about cough?

A

Is the cough normal for you?

27
Q

What is the normal amount of sputum for an adult?

A

Approx 100mL per day

28
Q

What do you need to consider about sputum?

A
  • Colour (usually white, clear & mucoid)
  • Consistency
  • Amount
  • Daily pattern
  • Ease of clearing
29
Q

What is haemoptysis?

A

Blood in the sputum

30
Q

When is excess sputum most common?

A

In suppurative lung diseases, e.g. cystic fibrosis, bronchiectasis

31
Q

What is suppurative lung disease characterised by?

A

Chronic wet cough & progressive lung damage

32
Q

What are wheezes caused by?

A
  • Narrowing of major intrathoracic airway (asthma)

- Sputum or airway obstruction

33
Q

What is stridor?

A
  • Exaggerated wheezing
  • Extrathoracic obstruction
  • Mainly during inspiration
34
Q

What are the important components of social history?

A
  • Who do they live with
  • Where do they live
  • Support/services (e.g. meals on wheels)
  • Previous mobility/function/daily activities
  • Usual exercise tolerance
  • Smoking
  • Usual cough/sputum clearance
  • Previous physio Rx
35
Q

What are the essential hospital requirements for documentation?

A
  • Patient ID sticker on pages
  • Black pen
  • Write directly under previous entry, within margins
  • Date, time
  • Legible, error correction
  • Approved abbreviations
  • Consent documented
  • Risks/warnings
  • Discharge summary
  • Signed, print name, designation
  • Co-signed by supervisor
36
Q

What relevant communications should be documented?

A
  • Conversations with medical staff
  • Handovers from another physio
  • Instructions to nursing staff
  • Referrals
  • Discharge/transfer summaries
37
Q

What is the general agreement based on for medical notes?

A

Subjective
Objective
Assessment
Plan

38
Q

What needs to be documented during the initial assessment (only needs to be done once)?

A
  • HPI (Reason for admission, dates of procedures, progress/issues)
  • PHx (Known conditions/diagnoses, previous surgeries/procedures)
  • SHx (home situation, previous mobility, activities/sports, smoking/alcohol)
39
Q

What needs to be documented following every interaction with patients?

A
  • Subjective assessment
  • Objective assessment
  • Problem list
  • Treatment (Rx)
  • Reassessment (ReAx)
  • Goals (SMART)
  • Plan
40
Q

What needs to be documented in the objective assessment?

A
  • Obs stable/febrile
  • Resp (SpO2, FiO2, ABG, RR, auscultation, palpation, cough, observations)
  • Cardio (HR, rhythm, BP)
  • Functional (mobility, balance, STS, gait)
  • Attachments (IV, drains, IDC, monitors)
41
Q

What should be included in the physio plan?

A
  • Instructions for nursing staff
  • Patient’s independent physio program
  • When you plan to see them again
  • Goals/plan for subsequent treatment

CI1 (21 decks)

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