APPROACH TO PATIENT INTERVIEW Flashcards
what does HIPAA stand for?
Health Insurance Portability and Accountability Act - 1996
what entity developed HIPAA?
Department of Health and Human Services
HIPAA: designed to 1)__________________ to 2)___________________________ and other health information provided to 3)_______ _________, 4)___________, 5)___________, and other healthcare providers
1) provide privacy standards to 2)protect patients’ medical records
3) health plans, 4) doctors, 5) hospitals
definition: provides patents with access to their medical records and more control over how their personal health information is used and disclosed
HIPAA
definition: the covered entity or business associate did not know an reasonably should not have known of the violation
unknowing (1st tier of culpability)
definition: the covered entity or business associate knew, or by exercising reasonable diligence would have known, that the act or omission was a violation, but the covered entity or business associated failed to act with willful neglect
reasonable cause (neglectful) (2nd tier of culpability)
definition: conscious, intentional failure or reckless indifference to fulfill the obligation to comply with HIPAA. However, the covered entity or business associate corrected the violation within 30 days of the discovery that resulted in a violation
willful neglect – corrected (knowing but not willful) (3rd tier of culpability)
definition: conscious, intentional failure or reckless indifference to fulfill the obligation to comply with HIPAA., and the covered entity or business associate did not correct the violation within 30 days of the discovery that resulted in a violation
willful neglect – uncorrected (willful and brazen) (4th tier of culpability)
when finding a case that you want to present for your class or any other presentation in the future… (2 steps)
1) talk to preceptor, go through appropriate channels: every rotation site is different on how you must obtain this information
2) copy what you need (i.e. pre-op note, anesthesia record, etc) and blackout deny identifying information
what does JCAHO stand for?
the Joint Commission on Accreditation of Healthcare Organizations
definition: a non-profit organization that accredits more than 20,500 healthcare programs and services in the US
JCAHO
what are the JCAHO accreditation cycles for health care organizations vs. laboratories?
health care organization: 3yr accreditation cycle
laboratories: 2yr accreditation cycle
which organizations are awarded the decision of Accreditation by JCAHO?
organizations deemed to be in compliance with all or most of the applicable standards
what does “unannounced” mean in terms of JCAHO?
“unannounced” means the organization does not receive an advance notice of its survey date
the following are components of what?
identification sheet, admission h&p, consent forms, medication summary, nurses assessments, consultation notes, physician’s progress notes, physician’s order sheets, lab reports, radiology reports, op/procedure/anesthesia record, discharge summary
the patient chart
definition: includes demographic information (name, DOB, address, SSN), employment, insurance, responsible party/emergency contact
identification sheet
how often should identification sheets be updated?
every year
definition: includes date & time, identifying data, chief complaint, history of present illness incl. meds, allergies, habits, past history, family history, personal/social history, review of symptoms (ROS)
H&P: history
which vital signs are included in the H&P?
blood pressure, heart rate, respiratory rate, temperature, and O2 saturation
definition: includes skin, HEENT, thorax/lungs, breasts/axillae, musculoskeletal, cardiovascular, abdomen, peripheral vascular/nervous system & genital/rectal exam
H&P: exam of all systems (physical exam)
definition: components include: patient name & date, name and description of surgery, indication for surgery, risks and benefits of procedure, alternatives to procedure, patient’s signature, printed name, date, and time/surgeon’s signature
consent forms
what critical component of the consent form can delay surgery?
patient must be competent to make medical decisions
what are the two components of the medication summary?
1) list of patient’s current medications while in the hospital
2) dosage, route, frequency, and whether patient has received the dose at a particular time
definition: components include: history (health status, course of present illness, current management, patient’s reception of illness), psychological and social exam, physical exam (signs that can be measured like vital signs and exam itself), assessment tools (activities of daily living, glasgow coma scale, and pain scales (fifth vital sign – ex. rate pain 1-10))
nursing assessment
definition: similar to admission H&P notes but done by a subspecialty physician
consultation notes
definition: daily progress and plans of an admitted patient (inpatient) – in SOAP format
physician’s progress notes
define SOAP
Subjective (what the patient tells you)
Objective (found as part of your physical exam)
Assessment (problem list)
Plan (management)
what are the three components of the physician’s orders?
date & time, order, the physician’s signature
how must we correct errors to the medical record?
all errors detected in clinical entries must be corrected BY DRAWING A SINGLE, THIN LINE through the inaccurate entry (making certain the original entry is still legible) and then making the correction.
what should you do if there is no room to make a correction or amendment in close proximity to the error as possible?
make a notation referencing the location of the correction or amendment in the margin
normal BP for average healthy adult at rest
90/60 - 120/80
normal HR for average healthy adult at rest
60-100 bpm
normal RR for average healthy adult at rest
12-20 breaths per minute
normal temperature for average healthy adult at rest
97.8-99.1 ºF (36.6-37.3 ºC – a 0.7ºC difference)
normal pulse ox reading for average healthy adult at rest
95-100%
definition: pressure exerted by circulation blood upon the walls of blood vessels
blood pressure
what is blood pressure measured in?
mmHg
definition: the pressure exerted on the walls of the arteries during heart contraction
systolic BP
definition: the pressure exerted on the walls of the arteries during heart relaxation
diastolic BP
aka perfusion pressure
MAP (mean arterial pressure)
JNC7’s classification for prehypertensive
120-139/80-89mmHg
JNC7’s classification for stage 1 hypertensive
140-159/90-99mmHg
JNC7’s classification for stage 2 hypertensive
≥160/100mmHg
tachycardia is defined as a HR greater than:
100 bpm
bradycardia is defined as HR less than:
60 bpm
how do you obtain radial pulse
feel rate for 15sec, multiply X4; feel for rhythm
tachypnea is defined as:
> 20 breaths per minute
bradypnea is defined as:
definition: absent breathing
apnea
definition: difficulty breathing
dyspnea
definition: deep breathing
hyperpnea
definition: shallow breathing
hypopnea
definition: shortness of breath while laying flat
orthopnea
definition: apnea alternating with tachypnea
cheyne-stokes respirations
definition: deep labored hyperventilation associated with metabolic acidosis
kussmaul’s breathing
how does normal body temperature vary from day to night?
cooler temps in the morning, warmer temps at night
how does normal body temperature vary according to where it is taken?
axillary temperatures – 1ºC lower than oral
rectal temperature – 0.4-0.5ºC higher than oral
put the sources of obtaining core temperatures in order of reliability
pulmonary artery > distal esophagus > bladder > nasopharyngeal > rectal
how is pulse oximetry measured?
light of 2 different wavelengths passed through patient to a photodetector.
what does prn mean in the medication record?
pro re nata: as the circumstance arises; as needed
what four parts of the meds record should you take note of?
1) medication, 2) dose, 3) route, 4) frequency (scheduled vs prn)
definition: the process of really attending to what the patient is communicating, being aware of the patient’s emotional stat, and using verbal and nonverbal skills to encourage the patient to continue and expand
active listening
definition: identifying with the patient’s feelings and feeling the patient’s pain as if it were your own.
empathetic response
definition: facilitating the patient’s fullest communication; moving from open-ended to focused questions; avoiding “yes/no” questions; offering multiple choice questions, using continuers, and echoing
guided questioning
definition: does not involve speech, occurs continuously, and provides important clues to feelings and emotions: eye contact, facial expressions, posture, head position, movement, interpersonal distance, and placement of arms and legs
nonverbal communication
definition: an important way of making the patient feel accepted by legitimizing or validating his/her emotional experience
validation
definition: identifying and acknowledging the patient’s feelings; comes from being thorough and making the patient feel confident that their problems are understood and will be addressed
reassurance
definition: making explicit your desire to work with the patient in an ongoing way
partnering
definition: giving a capsule summary of the patient’s story during course of interview: indicates that you’ve been listening, can identify what you know and what you don’t know, and can give you some time if you are drawing a blank
summarization
definition: telling a patient when you are changing directions in an interview, giving the patient a greater sense of control
transitions
definition: making the patient an active participant in their care/plan
empowering the patient
list the 4 parts of preparation (for the patient interview)
- review medical record
- set goals for interview
- review clinical behavior & appearance
- adjust the environment
definition: helps you gather information and plan the areas you need to explore
reviewing the medical record
definition: before talking with patient, clarity your goals for the interview and balance provider-centered goals with patient-centered goals
setting goals
definition: making the interview setting as private and comfortable as possible
adjusting the environment
definition: a changing paradigm; communicating effectively with patients from every background; having an understanding of and respect for the cultures, traditions, and practices of a community
demonstrating cultural humility
definition: patient falls silent when collecting thoughts, remembering details, and deciding whether clinician can be trusted with certain information
the silent patient
definition: patient presents confusing array of symptoms and seems to have every symptom you ask about (a ‘positive review of systems’) or you can’t make sense of the patient’s story
the confusing patient
definition: unable to provide history b/c of illness. must determine if pt has ability to understand health related information and make medical choices based on reason
the patient with altered capacity
definition: patient babbles or talks continuously without room for intervention; give pt free rein for 5-10min, and try to focus on what seems to be the most important to the pt
the talkative patient
definition: patient that sobs/cries uncontrollably: respond with empathy, give permission to cry, offer a tissue, make a supportive remark
the crying patient
definition: reasons may be illness, suffered a loss, lack control of their lives, or feel powerless in the healthcare system. if pt is out of control, do not try to touch them and alert security
the angry or disruptive patient
how should you approach the interview across a language barrier?
find interpreter, make sure interpreter translates everything you say instead of summarizing, face patient and speak to them instead of looking at interpreter
definition: a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time
tolerance
definition: a state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
physical dependence
definition: a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. it is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving
addiction
C of the CAGE questionnaire
have you ever felt the need to CUT DOWN on drinking?
A of the CAGE questionnaire
have you ever felt ANNOYED by criticism of your drinking?
G of the CAGE questionnaire
have you ever felt GUILTY about drinking?
E of the CAGE questionnaire
have you ever had an EYE-OPENER to steady your never or get rid of a hangover?
Kubler-Ross 5 stages in a person’s response to death
- denial & isolation
- anger
- bargaining
- depression or sadness
- acceptance
name the three dimensions of cultural competence
- self-awareness
- respectful communication
- collaborative partnerships
definition: learning about your own biases
self-awareness
definition: working to eliminate assumptions about what is “normal.” learning directly from your patients as they are the experts on their culture and illness
respectful communication
definition: building your patient relationships on respect and mutually acceptable plans
collaborative partnerships
the four building blocks of professional ethics
- nonmaleficence
- beneficence
- autonomy
- confidentiality
definition: “first, do no harm”
nonmaleficence
definition: clinical needs to “do good” for the patient
beneficence
definition: patients have the right to determine what is in their own best interest
autonomy
definition: as a clinician, you are obligated not to repeat what you learn from or know about a patient
confidentiality
