Assessment Flashcards
Settings
- Hospital
- Clinic
Different types of notes
-Complete/Comprehensive/Expanded
-Inventory
-Interim
Problem-oriented
Complete note
- new patients
- strengthens pt-clinicain relationship
- baseline for future assessment
Inventory note
-related to complete, BUT not as detailed
Interim note
events between visits
Problem-oriented
- focused, basic
- established patientss
- focused concerns or symptoms
Parts of Compete note: hint 10 of them
- Identifying data
- CC
- HPI
- Meds
- Allergies
- PMH
- PSH
- Family history
- Personal & Social History
- Review of Systems (ROS)
Different types of questions
- open-ended
- closed/direct
- graded response
- leading
- mulitiple
Open-ended question
- beginner interviewer
- best for general information
Closed/direct
- when seeking specific information
- outlined CC
Graded response question
-1-10 scale
Leading question
- Limits information
- Risky
Mulitiple
-Novice
10 Interview techniques
- Facilitation
- Reflection
- Clarification
- Reassurance
- Empathy
- Confrontation
- Interpretation
- Validation
- Summarization
- Transition
Facilitation
- verbal/nonverbal
- Encourage pt to say more
Reflection
-Repeat what pt said
Clarification
-terms with multiple meanings
Reassurance
-DO NOT give false hope
Empathy
- verbal/nonverbal
- put in pt shoes
Confrontation
-disturbing behavior
Interpretation
-Restate and confirm
Validation
Acknowledge/legitimacy
Summarization
-To pt what you got out of their information
