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Clinical Methods > Class 1: Patient interview > Flashcards

Class 1: Patient interview Flashcards

1
Q

HIPAA

A

Health Insurance Portability and Accountability Act

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2
Q

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

A

HIPAA

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3
Q

Off limits patient identifiers:

A
  • No smaller than state
  • No dates
  • No numbers whatsoever (medical record, health plan)
  • No vehicle info
  • No device ID
  • no URLs
  • No pictures
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4
Q

Patient Chart includes:

A
  • 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
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5
Q

What includes:

  • demographic info
  • employment insurance
  • responsibility party?

Should be updated every year!

A

Face sheet aka Identification sheet

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6
Q

What includes:

  • Chief complaint
  • History of present illness
  • past history
  • family history
  • ROS
A

Admission history and physicial exam

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7
Q

What includes:

  • Name of surgery
  • risks and benefits of procedure?
A

Consent form

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8
Q

What includes:

  • psychological and social exam
  • physical exam like vital signs
  • activities of daily living
  • Glasgow coma scale
  • pain scales
A

nursing assessment

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9
Q
  • similar to admission H&P notes but done by a subspecialty physician
  • asks for input from consulting physician
A

consultation notes

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10
Q

What includes:

  • daily progress and plans of admitted patient
  • is presented in SOAP format?
A

physician’s progress notes

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11
Q

What the patient tells you is what part of SOAP?

A

Subjective

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12
Q

What is found as part of you physical exam is what part of SOAP?

A

Objective

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13
Q

Where is the problem list found in SOAP?

A

Assessment

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14
Q

What are normal blood pressure values?

A

90/60 - 120/80

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15
Q

What are normal pulse oximetry ranges?

A

95-100%

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16
Q

The pressure exerted on the walls of the arteries during heart contraction is:

A

systole

17
Q

What is the pressure exerted on the walls of the arteries during heart relaxation?

A

diastole

18
Q

What is also known as the perfusion pressure?

A

MAP

19
Q

MAP equation:

A

1/3 pulse pressure + DP

pulse pressure = SP -DP

20
Q

MAP > ___ mmHg to perfuse organs in normal patient.

MAP > ____ mmHg in hypertensive patient.

A

60

70

21
Q

Prehypertension is when systolic is ____ - _____ and diastolic is _____ - _______.

A

120-139

80-89

22
Q

Stage 1 hypertension: systolic is ____ - ____ and diastolic is ____-______.

A

140-159

90-99

23
Q

Stage 2 hypertension systolic is ____ - _____ and diastolic is _____ - ______.

A

160 and higher

100 and higher

24
Q

Normal heart rate is _____ to _____ BPM.

Bradycardia < ______.

Tachycardia > _____.

A

60 to 100

60

100

25
Q

Normal breaths per minute is ___ - ___.

Bradypnea < _____.

Tachypnea > ____.

A

12-20

12

20

26
Q

Deep breathing is also known as _______.

A

hyperpnea

27
Q

Shallow breathing is also known as _______.

A

hypopnea

28
Q

Shortness of breath while lying flat is also known as _______.

A

orthopnea

29
Q

Apnea alternating with tachypnea is also known as _________.

A

Cheyne-Stokes

30
Q

Labored hyperventilation associated with metabolic acidosis is also known ______ __________.

A

Kussmaul’s breathing

31
Q

Sensor that uses 2 different wavelengths that is passed through the patient to a photodetector

A

pulse ox

32
Q

What to note for medications:

A
  • name of medication
  • dose
  • route
  • frequency
33
Q

techniques of skilled interview

A
  • listening
  • questioning
  • nonverbal communication
  • empathetic responses
  • validation
  • reassurance
  • partnering
  • summarization
34
Q

Being an active member of the patient’s care is what technique used in a skilled interview?

A

partnering

35
Q

What does CAGE represent?

A
  • Cut down on drinking: ever feel need?
  • annoyed
  • guilty
  • eye opener?
36
Q

Kubler -Ross 5 stages in a response to ______ are:

A

death

BAD AD

  • denial
  • anger
  • bargaining
  • depression
  • acceptance
37
Q

If sexual advances persist from a patient, get a ______

A

chaperone

38
Q

What are the building blocks of professional ethics? (4)

A
  • nonmaleficence (“do no harm”)
  • beneficence (“do good”)
  • autonomy (patients have right to do what is their best interest)
  • confidentiality

Clinical Methods (9 decks)

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