Flashcards in Foundations Deck (42):
Goals of an interview
1. Understand the patient's Environment
2. Understand their Illness
3. Develop a problem List
4. Develop a Plan
5. Developed a Contract for care
(EPIC-L, environment, plan, illness, contract, list)
Take to get buzzed
annoyed with drinking
cut back want?
Car - been in car with driver drunk
Relax - drink to relax
Alone - drink alone?
Forget what you did
Family/friend want you to cut back
Trouble - have you gotten into trouble while drinking?
Scream at you?>
Call - what do you call your probem
Cause - what do you think caused it
Concern - what is yours
Cope - how do you cope with this
interview technique involving head nodding, expressing understanding and encourage them to keep going
Repeat what they're saying and clarify to show that you are listening
What do you mean? Clarify terms with multiple meanings
Duh + do not give false hope
Use for disturbing behavior
Restate and confirm
acknowledge and legitimize
Ask me three
What - is problem
How - should I do?
Why - should I do it?
What is the range of drinks one can have to be considered "low risk" for developing alcoholism?
Men: less than or equal to 14 drinks/week, and less than or equal to 4 on one occasion
Women: Less than 7 drinks/week, and less than 3 on one occasion.
What is the range of drinks one can have to be considered "high risk" for developing alcoholism?
Consuming more than the "low risk" ranges
Define binge drinking
Drinking so much in 2 hours to reach a BAC of 0.08 g/dL
What is the one part of the note that is okay to document, even though you did not personally do it?
What type of words should you avoid when writing a note?
Normal, poor, good.
If a patient defers or if you choose to omit something from your note, how should you document this?
State reason or that the patient declined.
What is the correct order of information in the note?
What are the six items needed to properly document medications?
Number of tablets
Last dose taken.
What are items in a SHx?
ORT AIDS METH
What are THE CHADS
Heart disease (CAD)
What goes on the left side of a note, must be present when writing a hand-written note?
True or false: it is acceptable to skip a line so that it makes your note easier to read.
What type of writing utensil should notes be written in
Blue or black ink pen
How do you make an error correction in a hand written note?
Cross it out (never erase), and date and initial next to it.
What do you have to do at the bottom of each page
Print and sign name
True or false, it is okay to summarize a section if it deals with chief complaints
What does PPE stand for?
Personal protective equipment
True or false: it is okay to recap a needle if using a one handed technique.
True, but generally, never recap needles--put them in the sharps container.
When is it required to wash your hands?
After contact with fluids, immediately after removing gloves, and between patients.
When is respiratory hygiene necessary? When is it necessary?
For any patient that has a cough.
At point of contact.
When are standard precautions necessary?
What bodily secretion is not considered dangerous?
True or false, you should take precautions when touching mucus membranes.
What part of your hand should be used when palpating?
The palmar side of your fingers/hand
What is the correct order of examination?