Clin Comm Acronyms Flashcards
PPP
History of Present Illness
Perspective__Prior Knowledge & Practices__Preferences__
Perspective
What is going on for you that this has come up?
How is it affecting you?
Past Knowledge and Practices
What do you know about [list topic] and its effect on the body?
What methods have you used previously to address this problem?
Have you spoken to any other health professional about this subject before?
Preferences
Do you already have an idea of what options you would prefer to help you with [topic]?
What are some things that you might be interested in? [list menu of possible choices]
MASH FM
Past Medical History
Student‐Doctor should ask all categories; expanding as needed.
Medical History What kinds of medical problems do you have?
Any current or prior medical conditions (acute or chronic)
Injuries
Immunizations
Health maintenance (ex. mammograms, colonoscopy, etc)
Allergies Do you have any allergies?
Food, environmental, drug
What happens
Surgical History Have you had any surgeries?
What
When
Did it help?
Hospitalizations Have you ever been hospitalized?
What
Where
When
Family History What diseases run in your family?
Any medical conditions that run in the family
How managed
Causes of death
Medications What medications are you taking?
Name, dosage, and frequency of each medication
FED TACOSSSS
Psychosocial History
FED TACOSocStrSpirSex – Student‐Doctor should select questions that are pertinent to the presenting
problem, beginning with the least sensitive questions first (based on patient characteristics. Expand as
needed.
Food Tell me about your diet.
Exercise What do you do for exercise? How often?
Drugs* Do you take any illegal drugs? Do you take any medications not prescribed for
you?
Street drugs
Prescription drug abuse in chronic pain syndromes
Other?
Tobacco* What tobacco products do you use? How much? How often? When did you
start?
Smoking cigarettes/cigars
Smokeless tobacco (chewing tobacco, vapor)
Alcohol* How much alcohol do you drink? How often? What kind?
Caffeine Coffee, tea, soda, chocolate
Occupation* What do you (did you) do for a living?
Social Support* Tell me about your social support.
Spouse, significant other
Friends/family
Support needed relative to presenting problem
Stressors* What stressors are you experiencing?
How might these be related to the medical complaint
How does the patient cope with stress?
Sexual History Do you have any sexual concerns at this time?
For women:
Obstetrical history (menarche, menopause, menstruation)
First day of last normal menstrual period
Pregnancy planning and prevention
Spirituality‐Cultural I’d like to know if you have any religious or personal health practices that I
should be aware of to better care for you.
*Required as minimum data set for Psychosocial History
BATHE
Emotion and Coping
Background: Use the stressors from FEDTACOSSSS as a lead in
Do a mini‐summary of what the patient has told you
Affect: “Can you describe your mood the past couple of weeks?”
Trouble: “What troubles you most about the situation?”
Handle: “What have you been doing to cope with [stress, depression, anxiety, etc.]?”
Empathy: any statement demonstrating why their reaction might be normal, that you can
understand how difficult their situation must be
a. “This is a tough situation to be in. It’s difficult to [situation], and you feel [emotion].”
The possibility of being laid off at work is a tough situation to be in. It’s difficult to not
know if you still have a job, and now your are feeling anxious and worried about it.”
b. “Anybody would feel [emotion], because it is stressful to [situation]”
Anybody would feel anxious and worried, because it is stressful to not know if you are
going to be able to pay your bills.
c. “Your reaction makes sense to me; it would be [emotion] to [situation].
“Your reaction makes sense to be; it would be really upsetting to think about losing a job
and the effect it would have on your finances.”
BATHE – Emotion handling
B Use the stressors from FEDTACOSSSS as a lead in. Do a mini‐summary of CC how the
stressors are related.
A What has your mood been like for the past couple of weeks?
T What has been troubling you the most?
H “What do you do to cope with (emotion)?”
E Provides statement(s) of validation and/or reassurance. “I can see how you would be
feeling (emotion) because (paraphrase why the patient’s may feel that way).”
SBAR
The situation is…(CC)
Your biggest concern is…(patient’s stated concern)
B The background is…(pertinent positive signs & symptoms)
Mention need for physical exam to gather more information
A My assessment is (problem) because (disease explanation)
R You are requesting (patient’s request)
HPI for chronic disease using 3Cs
Control, Compliance, and Complications
Current Control: Review blood pressure from vital signs
Is it at goal for the patient’s age and chronic conditions?
Share information with patient regarding current control
>60 years old: SBP <150, DBP <90
<60 years old: SBP <140, DBP <90
All adults, diabetes but no kidney disease: SBP <140, DBP <90
All adults, chronic kidney disease with or without diabetes: SBP <140, DBP <90
Ask if the patient does home readings, and if so, what the readings are
Verify that the patient is doing it correctly
Using validated blood pressure device
Using correct size cuff placed on bare arm (not over clothes)
Resting quietly for at least 5 minutes
Back supported
Feet on ground and uncrossed
No talking
Compliance:
Open ended inquiries that are non-judgmental are important to establish a partnership. Normalizing and asking permission are effective strategies.
Judgmental:
Do you take your medicine like you are supposed to?
Have you been making changes to your diet and exercise?
If you don’t follow your treatment plan, you are at risk for worsening health problems
Non-judgmental:
I know that remembering to take medication every day can be difficult. How often do you think you might forget your medication?
I know it is hard to eat healthy. If it’s okay with you, I’d like to talk to you more about that in a few minutes.
Inquire about medication side-effects
(Side effects will commonly affect adherence to the medication plan)
Complications:
Ask several high yield questions for each of the following
These are high incidence, high morbidity/mortality areas
Cerebrovascular Disease Any episodic or permanent symptoms like uneven smile? Numbness in face? One arm weakness? One arm numbness? Slurred speech? Strange speech?
Heart Disease
Any chest pain with activity (angina)?
Any SOB with activity (exertional dyspnea)?
Any SOB when lying flat (orthopnea)?
Any swelling in your feet or legs (edema)
the “4A” model for partnering for health behavior change
prior to the SBAR, initiate the “4A” model for partnering for health behavior change STEP 1. Ask STEP 2. Assess STEP 3. Assist STEP 4. Arrange
STEP 1 Ask Permission STEP 2 Assess Readiness to Change STEP 3 Assist with Behavior Change (Partner with the patient) STEP 4 Arrange for Follow-Up
STEP 1: Ask Permission (Invite the patient to partner with you)
Example: We’ve discussed several things along the way that will be important to address over time to help with your hypertension. These are [list the things]. Would it be okay if we talked more about that? Which of those would you prefer to work on first?
Step 2 Assess Readiness to Change
Using a 1 – 10 scale, ask the patient how motivated or ready they are to [quit smoking; improve diet; exercise more; cut back on alcohol; etc.].
1 = Not ready or willing at all at this time. 10 = Ready to change now
(See next page for descriptions)
Give feedback about what their Stage of Change means
Step 3 Assist with Behavior Change (Partnering)
Assist the patient in developing solutions.
Ask the patient for their own ideas
“What do you think it would take for you to get to a 10; to quit/change?”
The patient will tell you what they need
Match their needs with solutions to get them to the next stage
Your goal should be to help the patient get to the next stage.
If you try to push them beyond where they are at, you will get resistance (arguments, explaining why what you are asking them to do won’t work, or resignation – just saying yes or okay to end the conversation).
The next pages highlight strategies for each Stage
Step 4 Arrange for Follow-Up
Partner with the patient on a specified follow-up time frame.
It should be appropriate for the stage
Pre-contemplation: 1 month
Contemplation: 3 – 4 weeks
Preparation: 2 – 3 weeks
Action: Just prior to designated start date, OR if starting that day, then bring the patient back in 2-4 weeks for follow-up.
Stages of Readiness to Change
Pre-contemplation
1-3
Not ready at all
Doesn’t see that behavior needs to be changed
Not thinking about changing
Denial; does not believe it applies to them
Believes consequences are not serious
Contemplation 4-6 Thinking about change Sees problem, but not yet ready to change Is thinking about making changes May sound ambivalent
Preparation 7-8 Ready to plan for change Getting ready to change May already be experimenting with small changes
Action 9-10 Ready to implement change Is already taking definitive action to make changes May not be consistent yet
