Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
clinical skills
ch 5 Conducting a Patient Interview
| Question | Answer |
|---|---|
| important uses for the medical record | financial purposes; legal document;educational tool;statistical data;communication between staff; document and track patients progress |
| SOMR | source oriented medical record |
| SOMR is divided into the following sections | history and physical;progress notes;nursing notes;lab report; diagnostic reports |
| POMR | problem oriented medical record |
| POMR contains four stages | database;problem list; plan of action; progress notes |
| subjective; objective; assessment; plan are which types of note | SOAP |
| data that the patient reports | subjective data |
| information that the healthcare worker observes | objective data |
| subjective data includes | pain scale |
| objective data includes | vital signs |
| doctors diagnosis is included in which portion of the soap note | assessment |
| tests and procedures to be done and treatment for the diagnosis made can be found in which portion of the soap note | plan |
| administrative data in the medical record includes | demographics; insurance; correspondence; legal |
| clinical data in the medical record includes | medical history; physical exam;progress notes; medication record;phone reports; education sessions;lab documents; diagnostic reports; consults; reports from other services and institutions;flow sheets |
| features of the EMR | time efficient;better organization;communication between practices |
| pitfalls of the EMR | cost of software;training time and costs; system goes down; risk of private information being accessed |
| the push for the EMR was put forth by which president and was to be instituted by what year | President Bush by 2014 |
| security measures to ensure HIPPA compliance | back up files; encrypted passwords; restrict access to sites; change passwords on a regular basis |
| medical record rention | 7-10 years |
| proper disposal of paper medical records is done by | shredding |
| documentation do's | correct chart; document all encounters; chart thoroughly; chart accurately; correct spelling; date and time each entry; legible;use standard abbreviations |
| approved closing signature on medical records includes | first and last name followed by credentials |
| documentation dont's | Don't: procrastinate;diagnosis;document for someone else; alter records; allow someone else to document for you |
| reason patient is being seen | chief complaint |
| CC should be written in what | the patients own words |
| elaborates on patients progress between visits | progress note |
| documenting lab procedures should include | type of specimen;source specimen was obtained from; test performed in house or sent out |
| documenting in office procedures should include | name of test/procedure;where it was performed;results;who ordered the test |
| making corrections in a medical reocrd | draw a single line through the error, your intitals; enter correction |
| educational sessions should be documented where in the chart | progress note or educational log |
| refers to period of time that pt has experienced symptoms related to the CC | duration |
| exchange of information between HCW and pt that promotes physical and emotional well being | therapeutic communication |
| gestures, postures, facial expressions that communicate nonverbally with others | body language |
| over ___% of what is percieved is the direct result of body language and tone of voice | 90 |
| Helps convey compassion or concern when a pt is anxious or upset | touching |
| preparation;greeting and introduction;body;conclusion | stages of the pt interview |
| always address adult pt by using their | title and last name |
| this type of questioning is the most effective during the pt interview | open-ended |
| this type of questioning should be avoided except when following up on an open-ended question | closed ended |
| using medical terminology; diagnosing; advising and offering false reassurance are examples of | ineffective interview techniques |
| type of health history the covers the pt personal, family and social hx | comprehensive medical hx |
| combination of the chief complaint and history of present illness | episodic medical history |
| includes: previous health concerns, current health concerns,current medication list | personal medical hx |
| UCD, previous medical illnesses, previous injuries, surgical procedures, and immunizations are part of past medical hx(PMH) review of systems and chief complaint are part of | current health concerns |
| provides detailed information about present and past health of pt family members | family medical hx(FMH) |
| current medications should include | prescriptions, OTC and supplements |
| drug allergies should be documented in | red |
| refers to lifestyle questions | social hx |
| parts of the social hx include | alcohol, drugs, caffeine intake, smoking, diet, exercise,sexual practices |
| series of symptoms that are related to the pt chief complaint | history of present illness(HPI) |
| a 24 hour clock is referred to as | military time |
| closing professional signature includes | first and last name with title |
| this part of the complaint should always be in the patients own words | chief complaint (CC) |
| questions r/t the CC such as: color;location;duration;size;associated S&S are known as | HPI: history of present illness |
Created by:
clarevoyant1019
Popular Clinical Skills sets