Documentation, ROS, and Skills

Question 1

Clinician must possess

Answer 1

1. strong assessment skills
2. eagerness to learn
3. desire to give high quality care
4. patience
5. passion to help others
6. ability to leave prejudice at the door

Question 2

Subjective v. Objective

Answer 2

1. Subjective - Based on or influenced by personal feelings or emotions
2. Objective - Not influenced by personal feelings or opinions in considering a representing facts

Question 3

Physical examination

Answer 3

an evaluation of the body and its functions

Question 4

PE Techniques

Answer 4

1. Observation
2. Palpation
3. Percussion
4. Auscultation

Look, Listen, Touch, smell

Question 5

Why Critical observation is important?

Answer 5

Observe, carefully and thoughtfully. The PE is an important component of clinical diagnosis.

Clinicians need to use an unbiased visual observation and inspection.

This interested observation, canprovide critical accurate information to the diagnostic exam.

Question 6

Palpation

Answer 6

Examination by:
Pressing on the surface of the body to feel the organs or tissues underneath

Question 7

Percussion

Answer 7

A method of tapping body parts with fingers, hands, or small instruments as part of a physical examination.

Question 8

Auscultation

Answer 8

Listening to sounds of the body during a physical exam.

Question 9

PE process

Answer 9

1. The process of
   evaluating objective anatomic findings through the use of:
   Observation, Palpation, Percussion, and Auscultation.
2. The information obtained must be thoughtfully integrated with the patient’s history and pathophysiology.
3. A thorough Physical Exam covers head to toe.

It measures important vital signs
Temperature
Blood pressure
Heart rate
Respiratory Rate

Question 10

Initial part of physical exam

Answer 10

1. Speech and appearance of Pt.

Question 11

Vital Signs

Answer 11

Useful in detecting or monitoring medical problems.

Vital signs can be measured in a medical setting, at home, at the site of a medical emergency, or elsewhere.

Question 12

Four main vital signs

Answer 12

1. HR
2. BP
3. Respiratory Rate
4. Body Temp

Question 13

What is considered an objective Fever?

Answer 13

at or greater than 100.4 f

Question 14

Pulse taking locations

Answer 14

1. Radial
2. Carotid
3. Femoral

Lower extremity -
1. Posterior tibial
2. Popliteal
3. Dorsalis pedis

Question 15

Reference systolic pressures without reading

Answer 15

1. Carotid - >80
2. Femoral - >70
3. Radial - > 60

Question 16

5 Main blood Pressure ranges
by the JNC

Answer 16

1. Normal <120/ <80
2. Elevated - 120-129/ <80
3. Stage 1 Hypertension -
   130-139 / 80-89
4. Stage 2 Hypertension -
   140-149 / 90-99
5. 150+ / 100+

Question 17

How to measure respiratory rate

Answer 17

count the number of breaths for an entire minute or count for 30 seconds and multiply that number by two

Question 18

What should you do prior to performing a physical examination on your patient?

Answer 18

1) Review the chart/including vs
2)Appear presentable
3) Create patient privacy

Question 19

Entering a patient room…

Answer 19

Knock on the door/wall
Introduce yourself
Verify pt’s name
Check ID bracelet
Make eye contact
Try to be at the pt’s physical level
Take notes
Repeat the plan back to the pt

Question 20

Pt. Interview techniques

Answer 20

1. Carefully attending to what the pt is endorsing
2. Connect to the pts emotional state
3. Use verbal and nonverbal skills to encourage the pt to expand on his or her feelings or concerns
4. Ask one question at a time
5. Clarify what the pt means

Question 21

When to use closed ended questions?

Answer 21

Use close-ended questions when you need a specific piece of information.

Does this hurt when you stretch?
The pain started today, right?
Are you feeling better today?
Do you have covid sxs?

Question 22

Interview approach overview

Answer 22

Start with Open-ended questions to hear “the story of the sxs”on the pts own words

Ask specific questions to elicit every symptom

End with closed-ended questions for the yes or no answers for “pertinent positives/negatives” for your ROS

Question 23

Non verbal communication

Answer 23

1. Consciously and unconsciously, you send messages through words and body-language
2. Posture, gestures, eye-contact with certain tone of voice can let the pt know if you are interested, attentive, or understand their concern.
3. Eye contact
   Posture
   Use of touch
   Staying silent
   Head nodding
   Facial animation
   Some forms of non-verbal communication are culturally bound

Question 24

What should you never assume in patient care?

Answer 24

1. Pt understands completely
2. Have the patient reiterate your plan

Question 25

Patient concerns to be mindful of.

Answer 25

Earnings Education status Inequalities of health care access Language Proficiency Pt care decision

Question 26

Implicit Bias

Answer 26

A set of unconscious philosophy or associations that lead to a negative evaluation of a person based on their perceived group identity This can negatively affect the patient encounter and contribute to disparities among various demographic groups

Question 27

Explicit Bias

Answer 27

The conscious and intentional decisions or preference is founded on beliefs of stereotypes or association based on a perceived group identity. Patient characteristics such as race, gender, sexual orientation, or age can influence aspects of the patient encounter.

Question 28

Medical ethics

Answer 28

Beneficence (doing good) Non-maleficence (do no harm) Autonomy (giving the patient the freedom to choose freely, where they are able) Justice (ensuring fairness)

Question 29

Informed Consent

Answer 29

Communication process in which a clinicals educates the patient about the risk/benefits/alternatives of a given procedure or intervention Be sure your patient has decision capacity, if not, please use a health care proxy Use an interpreter if needed Document Nature of the procedure and tx Risks Benefits

Question 30

Cinical encounter documentation

Answer 30

Goal: document in the pts health record to provide clear, concise, and detailed report that documents key findings and communicates your assessment in a brief format Must have order and clarity Almost all clinical information is subject to error as pts forget to mention certain sxs, fail to recount events of their illness, slant their stories. Clinicians can misinterpret pt. statements. Overlook info. Failed to inquire the one key question. React prematurely to dx and forget about the important part of the examination

Question 31

Keys for objectivity

Answer 31

Effective listening and feedback

Question 32

Patient expectations of clinicians

Answer 32

Empathy, Care, Compassion Ability of Clinician to listen and explain Knowledge/Skill Professionalism Show cultural competency/humility

Question 33

4 main areas of PE

Answer 33

1) Health/Medical History 2) Physical Examination 3) Clinical Reasoning and Assessment 4) Treatment Plan

Question 34

H&P categories

Answer 34

CC(Chief Complaint) HPI(History of Present Illness) Pmhx (Past Medical History) Pshx (Past Surgical History) Meds (Medications) Allergies PFHX (past Family history) Social Hx ROS (Review of Systems) Exam Labs Images/Other studies A&P (Assessment & Plan)

Question 35

CN VII/Facial nerve check

Answer 35

smile / frown