Class 1: Patient interview Flashcards
HIPAA
Health Insurance Portability and Accountability Act
Designed to provide privacy standards to protect patients medical records and other health information provided to health plans, doctors, hospitals, and other healthcard providers
Provides patients with access to their medical records and more control over how their personal health information is used and disclosed
HIPAA
Off limits patient identifiers:
- No smaller than state
- No dates
- No numbers whatsoever (medical record, health plan)
- No vehicle info
- No device ID
- no URLs
- No pictures
Patient Chart includes:
- Face sheet (identification sheet)
- admission history
- consent forms
- medication summary
- nurses assessments
- consultation notes
- physician progress notes
- order sheets
- lab reports
- radiology reports
- Op/procedure/anesthesia record
- discharge summary
What includes:
- demographic info
- employment insurance
- responsibility party?
Should be updated every year!
Face sheet aka Identification sheet
What includes:
- Chief complaint
- History of present illness
- past history
- family history
- ROS
Admission history and physicial exam
What includes:
- Name of surgery
- risks and benefits of procedure?
Consent form
What includes:
- psychological and social exam
- physical exam like vital signs
- activities of daily living
- Glasgow coma scale
- pain scales
nursing assessment
- similar to admission H&P notes but done by a subspecialty physician
- asks for input from consulting physician
consultation notes
What includes:
- daily progress and plans of admitted patient
- is presented in SOAP format?
physician’s progress notes
What the patient tells you is what part of SOAP?
Subjective
What is found as part of you physical exam is what part of SOAP?
Objective
Where is the problem list found in SOAP?
Assessment
What are normal blood pressure values?
90/60 - 120/80
What are normal pulse oximetry ranges?
95-100%
The pressure exerted on the walls of the arteries during heart contraction is:
systole
What is the pressure exerted on the walls of the arteries during heart relaxation?
diastole
What is also known as the perfusion pressure?
MAP
MAP equation:
1/3 pulse pressure + DP
pulse pressure = SP -DP
MAP > ___ mmHg to perfuse organs in normal patient.
MAP > ____ mmHg in hypertensive patient.
60
70
Prehypertension is when systolic is ____ - _____ and diastolic is _____ - _______.
120-139
80-89
Stage 1 hypertension: systolic is ____ - ____ and diastolic is ____-______.
140-159
90-99
Stage 2 hypertension systolic is ____ - _____ and diastolic is _____ - ______.
160 and higher
100 and higher
Normal heart rate is _____ to _____ BPM.
Bradycardia < ______.
Tachycardia > _____.
60 to 100
60
100
Normal breaths per minute is ___ - ___.
Bradypnea < _____.
Tachypnea > ____.
12-20
12
20
Deep breathing is also known as _______.
hyperpnea
Shallow breathing is also known as _______.
hypopnea
Shortness of breath while lying flat is also known as _______.
orthopnea
Apnea alternating with tachypnea is also known as _________.
Cheyne-Stokes
Labored hyperventilation associated with metabolic acidosis is also known ______ __________.
Kussmaul’s breathing
Sensor that uses 2 different wavelengths that is passed through the patient to a photodetector
pulse ox
What to note for medications:
- name of medication
- dose
- route
- frequency
techniques of skilled interview
- listening
- questioning
- nonverbal communication
- empathetic responses
- validation
- reassurance
- partnering
- summarization
Being an active member of the patient’s care is what technique used in a skilled interview?
partnering
What does CAGE represent?
- Cut down on drinking: ever feel need?
- annoyed
- guilty
- eye opener?
Kubler -Ross 5 stages in a response to ______ are:
death
BAD AD
- denial
- anger
- bargaining
- depression
- acceptance
If sexual advances persist from a patient, get a ______
chaperone
What are the building blocks of professional ethics? (4)
- nonmaleficence (“do no harm”)
- beneficence (“do good”)
- autonomy (patients have right to do what is their best interest)
- confidentiality
