chapter 36 (patient interview)

Question 1

what is the first step in the exam process?

Answer 1

patient interview

Question 2

What must be posted in patient areas?

Answer 2

HIPAA information

Question 3

Feelings of worry, nervousness, or unease typically before an imminent event

Answer 3

Anxiety

Question 4

Sadness on various levels and loss of interest in daily activities

Answer 4

Depression

Question 5

What are some signs of physical abuse?

Answer 5

• head injuries
• skull fractures
• burns
• broken bones
• bruises

Question 6

Which type of abuse is more subtle?

Answer 6

Physiological

Question 7

Which demographics are affected most by abuse?

Answer 7

• women
• children
• elderly

Question 8

Which age group of women is most at risk for abuse?

Answer 8

20-24

Question 9

You should observe an elderly patient for abuse by watching their ___ signs

Answer 9

Nonverbal

Question 10

Use of substance that is not medically approved

Answer 10

Substance abuse

Question 11

Physical or psychological dependance on a substance

Answer 11

Addiction

Question 12

Most recent records displayed first

Answer 12

Reverse chronological order

Question 13

What are the 6 C’s of charting?

Answer 13

1. clients words
2. clarity
3. completeness
4. conciseness
5. chronological order
6. confidentiality

Question 14

What does SOMR stand for?

Answer 14

Source oriented medical record

Question 15

Information arraigned according to who supplied the data

Answer 15

SOMR

Question 16

What does POMR stand for?

Answer 16

problem oriented medical record

Question 17

Revolves around patients problems or conditions (medical history)

Answer 17

POMR

Question 18

What does SOAP stand for?

Answer 18

• subjective
• objective
• assessment
• plan

Question 19

Patient perception of their own words

Answer 19

Subjective

Question 20

true data

Answer 20

Objective

Question 21

Main reason the patient is being seen

Answer 21

Chief complaint

Question 22

What is included in the history of present illness?

Answer 22

1. where it began
2. where its located
3. how long
4. what makes it better/worse
5. severity

Question 23

What is included in patient history?

Answer 23

• medical
• surgical
• family
• social

Question 24

What does ROS stand for?

Answer 24

Review of symptoms

Question 25

Doctor uses exam data to arrive at preliminary diagnoses

Answer 25

Assessment

Question 26

What is included in the doctors "plan"?

Answer 26

- treatment - referral - medication - therapy - testing - pt education

Question 27

A patient chart is considered a ___ document

Answer 27

Legal

Question 28

Questions that allow the patient to elaborate

Answer 28

Open-ended questions

Question 29

Questions that can only be answered with "yes" or "no"

Answer 29

Closed-ended questions

Question 30

What is the equation for converting C to F?

Answer 30

C(1.8)+32

Question 31

What is the equation for converting F to C?

Answer 31

F divided by 1.8 -32

Question 32

What does the P in PQRST stand for?

Answer 32

Provoking - what brought on the symptoms? Palliative - what makes it feel better?

Question 33

What does the Q in PQRST stand for?

Answer 33

Quality - what type of pain? Quantity - how often?

Question 34

What does the R in PQRST stand for?

Answer 34

Radiation - does the pain move to other parts of the body?

Question 35

What does the S in PQRST stand for?

Answer 35

Severity - how bad is it? Symptoms - any other symptoms?

Question 36

What does the T in PQRST stand for?

Answer 36

Timing - when did it come on? Triggers - does anything trigger the pain?

Question 37

SOAP format should always be in ___ order

Answer 37

chronological

Question 38

Every SOAP entry should be ___ and ___

Answer 38

signed and initialed