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Flashcards in Foundations Deck (42):
1

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)

2

CAGE

concern
annoyed
guilt
eye opener

3

TACE

Take to get buzzed
annoyed with drinking
cut back want?
Eye opener

4

CRAFFT

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?

5

HITS

Hurt you?
Insult you?
Threaten you?
Scream at you?>

6

Four Cs

courtesy
comfort
connection
confirmation

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

7

Facilitation

interview technique involving head nodding, expressing understanding and encourage them to keep going

8

Reflection

Repeat what they're saying and clarify to show that you are listening

9

Clarification

What do you mean? Clarify terms with multiple meanings

10

Reassurance

Duh + do not give false hope

11

Empathy

Duh

12

Confrontation

Use for disturbing behavior

13

Interpretation

Restate and confirm

14

Validation

acknowledge and legitimize

15

Ask me three

What - is problem
How - should I do?
Why - should I do it?

16

SIGE CAPS

Sleep
Interest lost
Guilt
Energy
Concentration
Appetite
Psychomotor (anxiety
Suicidal thoughts

17

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.

18

What is the range of drinks one can have to be considered "high risk" for developing alcoholism?

Consuming more than the "low risk" ranges

19

Define binge drinking

Drinking so much in 2 hours to reach a BAC of 0.08 g/dL

20

What is the one part of the note that is okay to document, even though you did not personally do it?

Vital signs

21

What type of words should you avoid when writing a note?

Normal, poor, good.

22

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.

23

What is the correct order of information in the note?

CC
HPI
Meds
Allergies
PMHx
Surgical hx
FMHx
SHx
ROS
PE
A&P

24

What are the six items needed to properly document medications?

Name
Dose
Frequency
Number of tablets
Route
Frequency
Last dose taken.

25

What are items in a SHx?

ORT AIDS METH

Occupation
Relationship
Tobacco
Alcohol
Illicit drugs
Diet
STDs
Military
Exercise
Travel
Hobbies

26

What are THE CHADS

Thyroid
HTN
Emphysema
Cancer
Heart disease (CAD)
Asthma
DM
Stroke

27

What goes on the left side of a note, must be present when writing a hand-written note?

Patient name/DOB
Headings

28

True or false: it is acceptable to skip a line so that it makes your note easier to read.

False

29

What type of writing utensil should notes be written in
?

Blue or black ink pen

30

How do you make an error correction in a hand written note?

Cross it out (never erase), and date and initial next to it.

31

What do you have to do at the bottom of each page

Print and sign name

32

True or false, it is okay to summarize a section if it deals with chief complaints

False.

33

What does PPE stand for?

Personal protective equipment

34

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.

35

When is it required to wash your hands?

After contact with fluids, immediately after removing gloves, and between patients.

36

When is respiratory hygiene necessary? When is it necessary?

For any patient that has a cough.
At point of contact.

37

When are standard precautions necessary?

FOR EVERYONE.

38

What bodily secretion is not considered dangerous?

Sweat

39

True or false, you should take precautions when touching mucus membranes.

True.

40

What part of your hand should be used when palpating?

The palmar side of your fingers/hand

41

What is the correct order of examination?

Inspect
Palpate
Percussion
Auscultation

42

What are the four Cs?

Courtesy
Comfort
Connection
Confirmation