Exam 2

Question 1

History of present illness (HPI)

Answer 1

• Document in chronological order
• use OLDCARTS
• should be a narrative (story)
• Factor in social determinates

Question 2

Review of systems (ROS)

Answer 2

• Review each body system head to toe

Question 3

Functional assessment

Answer 3

Allows us to assess whether or not pt is able to complete activities of daily living (activities of daily living aka ADL)

Question 4

Internal factors

Answer 4

ex: self esteem, health literacy, exercise, sleep/rest, spirituality, substance use

Question 5

External factors

Answer 5

ex: occupational health, living environment, relationships, abuse (trafficking, elder abuse, etc.)

Question 6

Mental status assessment (ABCT)

Answer 6

• Appearance: posture and position, body movements, dress
• Behavior: LOC, facial expression, speech, mood/affect
• Cognition: orientation, attention span, memory, judgement
• Thought process: thought content, perceptions, does what they say make sense?