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CLINICAL METHODS MIDTERM > APPROACH TO PATIENT INTERVIEW > Flashcards

APPROACH TO PATIENT INTERVIEW Flashcards

1
Q

what does HIPAA stand for?

A

Health Insurance Portability and Accountability Act - 1996

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2
Q

what entity developed HIPAA?

A

Department of Health and Human Services

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3
Q

HIPAA: designed to 1)__________________ to 2)___________________________ and other health information provided to 3)_______ _________, 4)___________, 5)___________, and other healthcare providers

A

1) provide privacy standards to 2)protect patients’ medical records
3) health plans, 4) doctors, 5) hospitals

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4
Q

definition: provides patents with access to their medical records and more control over how their personal health information is used and disclosed

A

HIPAA

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5
Q

definition: the covered entity or business associate did not know an reasonably should not have known of the violation

A

unknowing (1st tier of culpability)

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6
Q

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

A

reasonable cause (neglectful) (2nd tier of culpability)

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7
Q

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

A

willful neglect – corrected (knowing but not willful) (3rd tier of culpability)

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8
Q

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

A

willful neglect – uncorrected (willful and brazen) (4th tier of culpability)

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9
Q

when finding a case that you want to present for your class or any other presentation in the future… (2 steps)

A

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

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10
Q

what does JCAHO stand for?

A

the Joint Commission on Accreditation of Healthcare Organizations

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11
Q

definition: a non-profit organization that accredits more than 20,500 healthcare programs and services in the US

A

JCAHO

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12
Q

what are the JCAHO accreditation cycles for health care organizations vs. laboratories?

A

health care organization: 3yr accreditation cycle

laboratories: 2yr accreditation cycle

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13
Q

which organizations are awarded the decision of Accreditation by JCAHO?

A

organizations deemed to be in compliance with all or most of the applicable standards

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14
Q

what does “unannounced” mean in terms of JCAHO?

A

“unannounced” means the organization does not receive an advance notice of its survey date

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15
Q

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

A

the patient chart

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16
Q

definition: includes demographic information (name, DOB, address, SSN), employment, insurance, responsible party/emergency contact

A

identification sheet

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17
Q

how often should identification sheets be updated?

A

every year

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18
Q

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)

A

H&P: history

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19
Q

which vital signs are included in the H&P?

A

blood pressure, heart rate, respiratory rate, temperature, and O2 saturation

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20
Q

definition: includes skin, HEENT, thorax/lungs, breasts/axillae, musculoskeletal, cardiovascular, abdomen, peripheral vascular/nervous system & genital/rectal exam

A

H&P: exam of all systems (physical exam)

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21
Q

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

A

consent forms

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22
Q

what critical component of the consent form can delay surgery?

A

patient must be competent to make medical decisions

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23
Q

what are the two components of the medication summary?

A

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

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24
Q

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))

A

nursing assessment

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25
Q

definition: similar to admission H&P notes but done by a subspecialty physician

A

consultation notes

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26
Q

definition: daily progress and plans of an admitted patient (inpatient) – in SOAP format

A

physician’s progress notes

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27
Q

define SOAP

A

Subjective (what the patient tells you)
Objective (found as part of your physical exam)
Assessment (problem list)
Plan (management)

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28
Q

what are the three components of the physician’s orders?

A

date & time, order, the physician’s signature

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29
Q

how must we correct errors to the medical record?

A

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.

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30
Q

what should you do if there is no room to make a correction or amendment in close proximity to the error as possible?

A

make a notation referencing the location of the correction or amendment in the margin

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31
Q

normal BP for average healthy adult at rest

A

90/60 - 120/80

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32
Q

normal HR for average healthy adult at rest

A

60-100 bpm

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33
Q

normal RR for average healthy adult at rest

A

12-20 breaths per minute

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34
Q

normal temperature for average healthy adult at rest

A

97.8-99.1 ºF (36.6-37.3 ºC – a 0.7ºC difference)

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35
Q

normal pulse ox reading for average healthy adult at rest

A

95-100%

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36
Q

definition: pressure exerted by circulation blood upon the walls of blood vessels

A

blood pressure

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37
Q

what is blood pressure measured in?

A

mmHg

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38
Q

definition: the pressure exerted on the walls of the arteries during heart contraction

A

systolic BP

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39
Q

definition: the pressure exerted on the walls of the arteries during heart relaxation

A

diastolic BP

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40
Q

aka perfusion pressure

A

MAP (mean arterial pressure)

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41
Q

JNC7’s classification for prehypertensive

A

120-139/80-89mmHg

42
Q

JNC7’s classification for stage 1 hypertensive

A

140-159/90-99mmHg

43
Q

JNC7’s classification for stage 2 hypertensive

A

≥160/100mmHg

44
Q

tachycardia is defined as a HR greater than:

A

100 bpm

45
Q

bradycardia is defined as HR less than:

A

60 bpm

46
Q

how do you obtain radial pulse

A

feel rate for 15sec, multiply X4; feel for rhythm

47
Q

tachypnea is defined as:

A

> 20 breaths per minute

48
Q

bradypnea is defined as:

A
49
Q

definition: absent breathing

A

apnea

50
Q

definition: difficulty breathing

A

dyspnea

51
Q

definition: deep breathing

A

hyperpnea

52
Q

definition: shallow breathing

A

hypopnea

53
Q

definition: shortness of breath while laying flat

A

orthopnea

54
Q

definition: apnea alternating with tachypnea

A

cheyne-stokes respirations

55
Q

definition: deep labored hyperventilation associated with metabolic acidosis

A

kussmaul’s breathing

56
Q

how does normal body temperature vary from day to night?

A

cooler temps in the morning, warmer temps at night

57
Q

how does normal body temperature vary according to where it is taken?

A

axillary temperatures – 1ºC lower than oral

rectal temperature – 0.4-0.5ºC higher than oral

58
Q

put the sources of obtaining core temperatures in order of reliability

A

pulmonary artery > distal esophagus > bladder > nasopharyngeal > rectal

59
Q

how is pulse oximetry measured?

A

light of 2 different wavelengths passed through patient to a photodetector.

60
Q

what does prn mean in the medication record?

A

pro re nata: as the circumstance arises; as needed

61
Q

what four parts of the meds record should you take note of?

A

1) medication, 2) dose, 3) route, 4) frequency (scheduled vs prn)

62
Q

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

A

active listening

63
Q

definition: identifying with the patient’s feelings and feeling the patient’s pain as if it were your own.

A

empathetic response

64
Q

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

A

guided questioning

65
Q

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

A

nonverbal communication

66
Q

definition: an important way of making the patient feel accepted by legitimizing or validating his/her emotional experience

A

validation

67
Q

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

A

reassurance

68
Q

definition: making explicit your desire to work with the patient in an ongoing way

A

partnering

69
Q

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

A

summarization

70
Q

definition: telling a patient when you are changing directions in an interview, giving the patient a greater sense of control

A

transitions

71
Q

definition: making the patient an active participant in their care/plan

A

empowering the patient

72
Q

list the 4 parts of preparation (for the patient interview)

A
  1. review medical record
  2. set goals for interview
  3. review clinical behavior & appearance
  4. adjust the environment
73
Q

definition: helps you gather information and plan the areas you need to explore

A

reviewing the medical record

74
Q

definition: before talking with patient, clarity your goals for the interview and balance provider-centered goals with patient-centered goals

A

setting goals

75
Q

definition: making the interview setting as private and comfortable as possible

A

adjusting the environment

76
Q

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

A

demonstrating cultural humility

77
Q

definition: patient falls silent when collecting thoughts, remembering details, and deciding whether clinician can be trusted with certain information

A

the silent patient

78
Q

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

A

the confusing patient

79
Q

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

A

the patient with altered capacity

80
Q

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

A

the talkative patient

81
Q

definition: patient that sobs/cries uncontrollably: respond with empathy, give permission to cry, offer a tissue, make a supportive remark

A

the crying patient

82
Q

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

A

the angry or disruptive patient

83
Q

how should you approach the interview across a language barrier?

A

find interpreter, make sure interpreter translates everything you say instead of summarizing, face patient and speak to them instead of looking at interpreter

84
Q

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

A

tolerance

85
Q

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

A

physical dependence

86
Q

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

A

addiction

87
Q

C of the CAGE questionnaire

A

have you ever felt the need to CUT DOWN on drinking?

88
Q

A of the CAGE questionnaire

A

have you ever felt ANNOYED by criticism of your drinking?

89
Q

G of the CAGE questionnaire

A

have you ever felt GUILTY about drinking?

90
Q

E of the CAGE questionnaire

A

have you ever had an EYE-OPENER to steady your never or get rid of a hangover?

91
Q

Kubler-Ross 5 stages in a person’s response to death

A
  1. denial & isolation
  2. anger
  3. bargaining
  4. depression or sadness
  5. acceptance
92
Q

name the three dimensions of cultural competence

A
  1. self-awareness
  2. respectful communication
  3. collaborative partnerships
93
Q

definition: learning about your own biases

A

self-awareness

94
Q

definition: working to eliminate assumptions about what is “normal.” learning directly from your patients as they are the experts on their culture and illness

A

respectful communication

95
Q

definition: building your patient relationships on respect and mutually acceptable plans

A

collaborative partnerships

96
Q

the four building blocks of professional ethics

A
  1. nonmaleficence
  2. beneficence
  3. autonomy
  4. confidentiality
97
Q

definition: “first, do no harm”

A

nonmaleficence

98
Q

definition: clinical needs to “do good” for the patient

A

beneficence

99
Q

definition: patients have the right to determine what is in their own best interest

A

autonomy

100
Q

definition: as a clinician, you are obligated not to repeat what you learn from or know about a patient

A

confidentiality

CLINICAL METHODS MIDTERM (5 decks)

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