Bates: Chapter 3 & 4 Flashcards
Types of health histories (4)
comprehensive
focused on problem-oriented
follow up
emergency
When documenting make every attempt to quote the patients _____.
own words
*CHIEF COMPLAINT IN DOCUMENTATION
To get a clear picture of the history of present illness use _____ or ______.
OLDCARTS or OPQRST
When documenting allergies make sure to ask about (4)
food insects medication environmental factors\ **** include reactions
When documenting ________ get the prescription information and if use is daily or as needed, it it is OTC or ______.
medications
herbal
Documentation should also include childhood illness and _____.
substance abuse
Documenting _______ is mandatory for all patients over 13 years of age that have used tobacco within 1 year prior to their arrival at hospital/clinic.
tobacco use
During the interview when asking about tobacco use make sure to get the length of use, how often, and the ______.
type of tobacco product
During the interview assess what patient’s consider alcohol. Then use the _____ tool.
CAGE
CAGE QUESTIONS
Have you ever felt the need to CUT DOWN on drinking?
Have you ever felt ANNOYED by criticism of your drinking?
Have you ever felt GUILTY about drinking?
Have you ever taken a drink first thing in the morning (EYE OPENER) to steady your nerves or get rid of a hangover?
During the interview process review all _____.
systems
During the review of the systems during the interview address _____ body system, from head to toe.
EACH
During the review of the systems during the interview you may uncover problems patient has ______.
overlooked
During the review of the systems during the interview do not use ______.
medical terms, use plain English
During the interview portion on sexual history make sure that you do not make _______.
assumptions about the patients
