Workshop #1- Interviewing/Health History Flashcards Preview

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Flashcards in Workshop #1- Interviewing/Health History Deck (64)
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1

closely attending to what the pt is communicating, connecting to the pt's ustate and using verbal and nonverbal skills to encourage the pt to expand on the feelings or concerns

Active Listening

2

You have to be able to covey that you are feeling what the pt is feeling. You need to be able to listen and see what and or how this is bothering the pt. A loss of a parent: can be terribly sad for some and a burden lifted for others

Empathetic Response

3

Move from _________ to more ________ questions

open ended; focused

4

Ask questions that require a _______ response as in "how many steps can you walk before becoming SOB?"

graded

5

Notice this and bring it to a conscious level. Watch for facial expression closed or open body language, posture, head position. Remember some cultures that they may be bound by

Nonverbal Communication

6

Confirm that what they are saying is legitimate. If in a car accident and unhurt validate that it must have been scary.

Validation

7

First identify and acknowledge the patients feelings; you seem upset today? If you tell them right off everything is going to be okay you have not heard the complete story yet and do not know what the out come is. Wait till the end and after testing and exam is done let them know what you think is going on. They tend to like to be heard and by doing this they feel that you are giving the care they need.

Reassurance

8

When building rapport express commitment to an ongoing relationship and that no matter what you will continue to provide care.

Partnering

9

telling the patients story back to them it shows them you have been listening and gives them a chance to correct things you may not have correct. It allows you to organize your clinical thinking and convey your thinking back to the patient.

Summarization

10

Tell the patient when you are changing to another area in the interview so they feel like they know what is going on. This helps them prepare for what is coming next. Now I’d like to ask f=some questions about… or before we move n to reviewing your medications is there anything else about your past health problems?

Transitioning

11

The patient can feel venerable. By making them feel they can ask questions, express their concerns and inquire about your recommendations, they can feel they empowered in their care and are more apt to adopt your advice, change their lifestyle, and take medication you prescribe.

Empowerment

12

data that the patient tells you

Subjective

13

data that you obtain through observation, assessment, labs, diagnostic tests, etc.

Objective

14

Purpose of ________ Visit:
To establish care
Needs a complete physical for work or school
Wants a “complete check up)

Comprehensive

15

30-60 scheduled visit

Comprehensive

16

15-20 minute walk-in or same-day visit

Episodic

17

History in the ____________ Exam:
Gather as much information about the patient such as:
Health and wellness
Illness and disease
All aspects of life that affect any of the above

Comprehensive

18

Physical Exam in the ____________ Exam:
Head to toe
Every system examined

Comprehensive

19

Physical Exam in the ____________ Exam:
May include all chronic health problems, newly established health problems

Comprehensive

20

Planning in the ____________ Exam:
More extensive
May have more health maintenance and preventive aspects to it

Comprehensive

21

Purpose in the ____________ Exam:
Acutely ill
Has a specific complaint
Requires a specific follow up from a previous visit
Requires a medication refill

Episodic

22

History in the ____________ Exam:
To gather as much information as quickly as possible.
One specific issue
Anything that affects that one specific issue

Episodic

23

Physical Exam in the ____________ Exam:
Only the systems that are required for THIS specific complaint

Episodic

24

Assessment in the ____________ Exam:
Typically includes a diagnosis(ES) ONLY for the problem dealt with today

Episodic

25

Planning in the ____________ Exam:
Targeted. Plan addresses what is going on with the patient today.

Episodic

26

Documentation for _________:
CC (Chief Complaint)
HPI (History of Present Illness)
Active Medical History
Past Medical History (PMH)
Childhood,
Adult,
Surgical,
ER/Accidents/Injuries
Women’s Health,
Psychiatric
Health Screenings/Health Maintenance
Medications
Allergies
Immunizations
Family History-3 generations
Social History
Tobacco, alcohol, illicit drugs, home, school, work, family situation, interests, hobbies, domestic violence screening, pain, safety, diet/nutrition, exercise/ADLs, spirituality, sexuality
ROS (Review of Systems) Review ALL systems with patient

Comprehensive Visit

27

Documentation for ____________:
**CC
**HPI
**Active Medical History
Past Medical History (Childhood, Adult, Surgical, ER/Accidents/Injuries, Psychiatric, Health Maintenance)
**Women’s Health
**Medications
**Allergies
**Immunizations
Family –only if pertinent
Social- Hx as pertinent
ROS (Review of Systems)
**Systems reviewed with patient are targeted

Episodic Visit

28

Past Medical History in the ___________ visit includes Childhood, Adult, Surgical, ER/Accidents/Injuries, Psychiatric, and Health Maintenance but you only ask about what is pertitent to the chief complaint

Episodic

29

In the __________ visit, only ask about family history if it's pertinent to the chief complaint

Episodic

30

the way notes are always written by all medical staff so there is no confusion from provider to provider.
It provides a cognitive framework to guide healthcare workers in their clinical reasoning to assess, diagnosis, and treat a patient

SOAP Framework

31

SOAP=

Subjective
Objective
Assessment
Plan

32

___________ and ____________ data should not bleed into each other

Subjective and Objective

33

The reason they are here today “in quotes”

Chief Complaint

34

The story they have about their chief complaint

History of Present Illness

35

Medical Problems for which they are currently being treated, diagnosed when, does what for it?

Active Medical History

36

Any medical problems from the past which they are not currently being treated for. (Date, complications and/or sequelae)
There are many subcategories here which are listed .
In a complete health history cover them own.
In an episodic pick and choose

Past Medical History

37

there should ALWAYS be a subcategory of _____________ for any woman of childbearing age under Past Medical History. The information which MUST be covered here is Last Menstrual Period and form of contraception.

Womens Health

38

Name of medication, dose, frequency

Medications

39

Always ask specifically about medication, food, animals, environmental and latex. Indicate the reaction.

Allergies

40

Outline or diagram of age, cause of death across 3 generations for a complete history
For the episodic visit stay targeted

Family History

41

Education, Family, Household, Personal interests, Lifestyle, Employment

Personal/Social History

42

The garbage can of the entire history
Always comes at the very end of the ENTIRE history
Last chance to ask any questions/document answers not completely covered in the rest of the history
Last chance to ask questions/document patient answers you may have forgotten to ask
The framework for asking and documenting is still structured
Use Systems format – Head to Toe
Questions are more directive – get “yes” and “no” responses.
Will get a lot of “nos”
A negative response to certain questions about symptoms is just as important as a positive response in assessment. This is called a “significant negative”

Review of Systems

43

The Review of Systems is _________ only, NOT the physical exam.

subjective/history

44

This is the (Symptom Analysis)
The PRINCIPAL symptom should be characterized using OLDCARTS
Get “pertinent positives” and “pertinent negatives”
If the patient has more than one PRINCIPAL symptom, then make a separate paragraph for each principal symptom
What you put in the HPI is not dependent on where the patient told you something in the interview.
Follow the patient’s lead…BUT…YOU keep it organized in the interview and on paper.

History of Present Illness

45

O
L
D
C
A
R
T
S
+1

Onset
Location
Duration
Characterization
Alleviating/Aggravating Factors
Radiation
Timing
Severity
Patient's Thoughts

46

Characterization of the symptom means...

how the patient describes the symptom

47

Timing of the symptom means....

improvement/worsening of the symptom of the during certain times of day

48

Always documenting how the patient states their words, not in your words.
Documenting it in quotes “ I can’t stop coughing at night”.
Documenting what you see and make sure to use all systems that are needed for the visit.
Documenting in the SOAP format so all providers can read without confusion

Accuracy and Precision

49

SOAP framework ensures _______ and _________

Accuracy and Precision

50

Type of screening tools that are those that the provider asks the patient while completing the history
may indicate the need for further investigation of a particular issue.
EX: alcohol screening and domestic violence screening.
commit to memory

Informal

51

Type of screening tools that are paper/pen format, and usually require "scoring" - or quantifying in some manner.
May require special training, education, preparation

Formal

52

_________ questions - alcohol
Use if you feel there has been hedging or vagueness on initial response

CAGE/TWEAK

53

_______ questions- check your state statutes regarding mandatory reporting of suspected domestic violence

SAFE

54

_____% of trafficked women in the U.S. saw a health care provider or professional during the time they were still being held captive. Family Violence Prevention Fund (2010)

28

55

Examples of __________:
Depression Screening:
PHQ-2
Beck Inventory
Zung Questionnaire
MMSE (mini-mental status exam)

Formal Screening Tools

56

Evaluate _________ for:
Reliability
Validity
Specificity
Sensitivity

Screening Tools

57

LR of 3 increases probability by ___%

20

58

LR of 0.3 decreases probability by ____%

25

59

Which factors are major components of a client's general background history

Socioeconomic Status and Allergies

60

The Review of Systems is _______ data

subjective

61

Likelihood Ratios convey to the provider:

diagnostic weight of the sign or symptom

62

Level of evidence scales are rating scales that provide the clinician with the _________ of evidence

STRENGTH

63

When subjective data argues against or refutes your hypothesis, this is known as a:

confounder

64

To measure the reliability of judgments of multiple observers, you would use a statistical measure of:

interrater reliability