Patient Interview

Flashcard maker : Brandon Ruffin
The first step in the examination process is the patient interview.
TRUE
When recording in a patient’s chart, summarize what the patient says in your own words.
FALSE
Passive listening is listening to and thinking about what the patient says and responding.
FALSE
A patient’s agitation and raising of his voice in anger can be a warning that he may become violent.
TRUE
Substance abusers are also called addicts.
FALSE
A patient can recover physically from abuse, but the emotional and psychological scars may last a lifetime.
TRUE
Neglect is a form of child abuse.`
TRUE
The information contained in the patient’s chart is used primarily to guide the physician during future office visits.
FALSE
When interviewing the patient, what the patient says is more important than the body language, which may just be a habit.
FALSE
When gathering symptom information from a six year old it is not appropriate or effective to focus on his interpretation of the situation, but rather focus on the parent’s.
FALSE
Depression affects primarily adolescents.
FALSE
The person who has been \”successful\” and has recently retired is at very low risk of becoming depressed.
FALSE
The six C’s of charting include cohesiveness.
FALSE
A discharge summary is added to the patient’s chart when he is no longer receiving care from your office.
FALSE
Charting is done primarily for \”in house\” use by the practitioner(s), so use of shorthand abbreviations is acceptable practice.
FALSE
In charting, subjective data includes the
a. test results.
b. physician’s examination.
c. patient’s chief complaint.
d. vital signs.
C
The physician’s diagnosis or impression of the patient’s problem is the
a. subjective data.
b. assessment.
c. objective data.
d. plan of action.
B
Which of the following would you document under the plan of action?
a. the medications prescribed and the tests to be done
b. the physician’s diagnosis
c. the patient’s chief complaint
d. the results of the physician’s examination
A
Which of the following is a factor in successful interviewing?
a. tell the patient that you \”need to take a history\”
b. avoid the use of icebreakers
c. give the patient your opinion about a diagnosis
d. assist the patient to a private room and close the door
D
Which of the following methods of collecting patient data requires more than a yes or no answer and encourages the patient to more fully explain the situation?
a. asking leading questions
b. challenging a patient
c. asking open-ended questions
d. focusing on the patient
C
Mirroring means
a. blocking further communication.
b. restating what the patient says in your own words.
c. interpreting what you believe the patient is saying.
d. motivating the patient to describe the situation in his own way.
B
Where would you like to begin?\” is an example of which method of collecting patient data?
a. challenging the patient
b. asking hypothetical questions
c. encouraging the patient to take the lead
d. asking open-ended questions
C
\”You seem to be making progress, don’t you agree?\” is an example of which method of collecting patient data?
a. asking leading questions
b. asking hypothetical questions
c. asking closed-ended questions
d. asking open-ended questions
A
Which of the following offers the patient little freedom to explain his answers and requires only yes or no answers?
a. probing
b. agreeing or disagreeing with the patient
c. asking leading questions
d. asking closed-ended questions
D
Which of the following is characteristic of depression?
a. occurs most commonly in children
b. the signs of depression are the same as the signs of substance abuse or addiction
c. symptoms include difficulty falling asleep, loss of appetite and energy
d. depression is always easy to diagnose
C
Which of the following commonly abused drugs are amphetamines/stimulants?
a. phenobarbital and amobarbital
b. valium, ativan, and librium
c. dexedrine, benzedrine, and methamphetamine
d. butisol and secobarbital
C
Which of the following are side effects of LSD?
a. slowed thinking, slowed reflexes, slowed respiration, loss of anxiety
b. heightened sense of awareness, grandiose feelings, hallucinations, mystical experiences, flashbacks
c. decreased level of consciousness, detachment, drowsiness, impaired judgment
d. altered mental status, confusion, paranoia, hyperactivity followed by exhaustion, insomnia, loss of appetite
B
Which of the following are other names for cocaine?
a. coke, snow, crack
b. acid, microdot
c. pot, grass, reefer
d. angle dust
A
Angel dust is also known as
a. LSD.
b. cocaine.
c. PCP.
d. opium.
C
The information in the patient’s chart is primarily
a. a reminder to the provider of what has occurred in the past.
b. for the third party payer’s use.
c. mechanism to provide continuity of care for the patient.
d. a legal record of treatment rendered.
D
During an interview of a patient, you note signs of anxiety in the patient. You may be able to help the patient by
a. stopping the interview.
b. letting him take the lead.
c. bringing in the physician.
d. allowing him to describe his feelings.
D
Which of these patient behaviors are classic for depression?
a. a profound sadness
b. a sense of impending doom
c. obsession with exercising
d. anxiety about entering the health care system
A
When charting, the need for ____ makes it essential that you use medical terminology and precise descriptions.
a. conciseness
b. completeness
c. clarity
d. confidentiality
C
a privacy notice must be prominently posted within the hospital
HIPAA
know the long term costs of treatment choices
PATIENT’S BILL OF RIGHTS
To know the identity of persons involved in care.
PATIENT’S BILL OF RIGHTS
Patient consent is necessary to disclose information for treatment or payment
HIPAA
healthcare facilities must inform patients, in writing, about disclosure of identifiable health information
HIPAA
be informed of available resources of resolving disputes
PATIENT’S BILL OF RIGHTS
agreeing with the patient
INEFFECTIVE
asking questions that require yes or no answers
INEFFECTIVE
asking hypothetical questions
EFFECTIVE
encouraging the patient to evaluate his situation
EFFECTIVE
asking open-ended questions
EFFECTIVE
probing for more information
INEFFECTIVE
asking leading questions
INEFFECTIVE
encouraging patient to take the lead.
EFFECTIVE
\”Do you have a cough?\”
ASKING CLOSED-ENDED QUESTIONS
\”Can you tell me about your symptoms?\”
ASKING OPEN-ENDED QUESTIONS
\”What would you do if you had chest pain?\”
ASKING HYPOTHETICAL QUESTIONS
\”So let me see if I understand. You are saying that the pain only occurs at night.\”
VERBALIZING THE IMPLIED
Maintain eye contact
FOCUSING ON THE PATIENT
\”Are you sure about that? It doesn’t make sense to me.\”
CHALLENGING THE PATIENT
\”What do you think is going on with you?\”
ENCOURAGE PATIENT TO EVALUATE HIS SITUATION
Assume an open and relaxed body posture
FOCUSING ON THE PATIENT
\”Where would you like to begin?\”
ENCOURAGING PATIENT TO TAKE THE LEAD
increased heart rate and BP
ECSTASY/PSYCHOACTIVE
decreased heart rate and BP
GNB/DEPRESSANT
mystical experiences
LSD
distorted sense of time and self
MARIJUANA/HASISH
hearing loss, spasms in extremities
INHALANTS
heightened sense of awareness
LSD
aggression
ANABOLIC STEROIDS
confusion
ECSTASY/PSYCHOACTIVE
measurable information like vital signs
OBJECTIVE
the type of treatment chosen, medications, tests, patient education, etc.
PLAN
the type of treatment chosen, medications, tests, patient education, etc.
SUBJECTIVE
the impression of the patient’s problem
ASSESMENT
may have a space for patient remarks following a section for the doctor’s comment
CONVENTIONAL
uses a combination of SOMR and POMR
COMPUTERIZED MEDICAL RECORDS
method used most extensively
PROBLEM ORIENTED MEDICAL RECORDS
includes the database, problem list, treatment plan and progress notes.
PROBLEM ORIENTED MEDICAL RECORDS
information about the health of the patient’s family
FAMILY HISTORY
information about when the problem started and what the patient has done to treat it
HISTORY OF PRESENT ILLNESS
questions about and examination (by the practitioner) of all body functions
REVIEW OF SYSTEMS
the reason the patient came to visit the practitioner
CHIEF COMPLAINT
includes important information about medications (including herbal and OTC) and allergies
PAST MEDICAL HISTORY
information taken from the administrative sheet
PERSONAL DATA
will give practitioner information about exposure to hazardous substances, sexual practices and chemical use habits
SOCIAL AND OCCUPATIONAL HISTORY

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