Chapter 28 & 29 Pt. Assesment & Education – Flashcards
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Past history
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This section of the Medical History that helps uncover existing or potential health problems
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The privacy of the area in which the interview takes place
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Which is likely to have to most influence on the accuracy and completeness of the information obtained from the patient during the medical history
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Problem Oriented
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Which medical record system has a standard format that makes it easy to read and audit?
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symptom
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During the Physical exam, the pt reports a continual ache in the right elbow. This info is call a
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Database
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Which of the following includes insurance info
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database
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Which of the following includes demographic info
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ROS
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Which of the following sections of the medial record includes the physical exam finding
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Social history
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Which of the following includes the pts dietary habits, smoking, alcohol
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Clarification
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Which of the following involves asking a question or summarizing a pt thoughts
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what brings you to the office today?
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Which is an open-ended question
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Subjective
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Information that you gather from a pt interview is
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Tell me about how your arm feels righ now
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Which questions would encourage the pt. to continue to communicate
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Elevated blood pressure
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Which explains a sign of disease
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Providing uninterrupted privacy
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Which is the most important when conducting a patient interview
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perception of the disease, age, emotional state, learning style.
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Factors that affect patient learning
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Patient w/ vision loss.
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All written material should be in large font or large print for which of the following pts.
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A patient with hearing loss.
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Who benefits most if you stand in front of pt or withing the persons field of vision before beginning to speak
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Releasing pt information only to those identified on the patient authorization form
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HIPAA restrictions on PHI dictate
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Use language that is a 6 to 8 grad level
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When developing a pt education pamphlet on diabetes mellitus. What is important
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Closed
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How have you been feeling? is what kind of question
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Open
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Tell me about your back pain, is what kind of question
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Closed
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Do you smoke? is what kind of question
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closed
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When did the nausea start? is what kind of question
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Subjective
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Pain is what form of question
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Subjective
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Nausea is what form of question
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Subjective
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Dizziness is what form of question
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objective
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Labored respiration is what form of questions
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Objective
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Color of the skin is what form of question
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Subjective
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Back pain is what form of question
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Subjective
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Abdominal pain is what form of question
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ac
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before eating
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hour of sleep
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hs
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treatment
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Rx
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twice a day
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bid
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Power of attorney
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This legal document must be signed by the patient inorder to authorize a attorney to see their records
