Patient History Flashcards
1
Q
SOAP
A
CC HPI PMH Fam hx Soc hx ROS - all subjective vitals physical exam - both objective assessment plan
2
Q
ROS
A
General Head Eyes Ears Nose/sinuses Mouth/throat/neck Cardiac Respiratory GI Urinary Breasts Gyn Skin Vascular MSK Neuro Heme Endocrine Psychiatric
3
Q
Focused history
A
Covers only what is pertinent to the cc; general rule: new pt = full, returning = focused; new patients may get a focused if they’re unable to give a full or it’s an emergency
4
Q
Cardinal principles of PE
A
Inspection: begins when you walk in the room
Auscultation: pt voice then steth
Percussion: body surface struck to emit sounds that vary in intensity; tympany - air filled stomach, resonance - air filled lungs, flatness - solid muscle
Palpation: tenderness, texture, temp, tone, masses
5
Q
Plan
A
F/u Additional tests and referrals Medications OMT Understanding of disease Self care
6
Q
Seven essential elements of healthcare communication
A
- ) open discussion
- ) build relationship
- ) gather info
- ) understand patient’s perspective
- ) share info
- ) reach agreement on problems and plans
- ) provide closure
