Foundations Flashcards
Goals of an interview
- Understand the patient’s Environment
- Understand their Illness
- Develop a problem List
- Develop a Plan
- Developed a Contract for care
(EPIC-L, environment, plan, illness, contract, list)
CAGE
concern
annoyed
guilt
eye opener
TACE
Take to get buzzed
annoyed with drinking
cut back want?
Eye opener
CRAFFT
Car - been in car with driver drunk Relax - drink to relax Alone - drink alone? Forget what you did Family/friend want you to cut back Trouble - have you gotten into trouble while drinking?
HITS
Hurt you?
Insult you?
Threaten you?
Scream at you?>
Four Cs
courtesy
comfort
connection
confirmation
Call - what do you call your probem
Cause - what do you think caused it
Concern - what is yours
Cope - how do you cope with this
Facilitation
interview technique involving head nodding, expressing understanding and encourage them to keep going
Reflection
Repeat what they’re saying and clarify to show that you are listening
Clarification
What do you mean? Clarify terms with multiple meanings
Reassurance
Duh + do not give false hope
Empathy
Duh
Confrontation
Use for disturbing behavior
Interpretation
Restate and confirm
Validation
acknowledge and legitimize
Ask me three
What - is problem
How - should I do?
Why - should I do it?
SIGE CAPS
Sleep Interest lost Guilt Energy Concentration Appetite Psychomotor (anxiety Suicidal thoughts
What is the range of drinks one can have to be considered “low risk” for developing alcoholism?
Men: less than or equal to 14 drinks/week, and less than or equal to 4 on one occasion
Women: Less than 7 drinks/week, and less than 3 on one occasion.
What is the range of drinks one can have to be considered “high risk” for developing alcoholism?
Consuming more than the “low risk” ranges
Define binge drinking
Drinking so much in 2 hours to reach a BAC of 0.08 g/dL
What is the one part of the note that is okay to document, even though you did not personally do it?
Vital signs
What type of words should you avoid when writing a note?
Normal, poor, good.
If a patient defers or if you choose to omit something from your note, how should you document this?
State reason or that the patient declined.
What is the correct order of information in the note?
CC HPI Meds Allergies PMHx Surgical hx FMHx SHx ROS PE A&P
What are the six items needed to properly document medications?
Name Dose Frequency Number of tablets Route Frequency Last dose taken.
What are items in a SHx?
ORT AIDS METH
Occupation Relationship Tobacco Alcohol Illicit drugs Diet STDs Military Exercise Travel Hobbies
What are THE CHADS
Thyroid HTN Emphysema Cancer Heart disease (CAD) Asthma DM Stroke
What goes on the left side of a note, must be present when writing a hand-written note?
Patient name/DOB
Headings
True or false: it is acceptable to skip a line so that it makes your note easier to read.
False
What type of writing utensil should notes be written in
?
Blue or black ink pen
How do you make an error correction in a hand written note?
Cross it out (never erase), and date and initial next to it.
What do you have to do at the bottom of each page
Print and sign name
True or false, it is okay to summarize a section if it deals with chief complaints
False.
What does PPE stand for?
Personal protective equipment
True or false: it is okay to recap a needle if using a one handed technique.
True, but generally, never recap needles–put them in the sharps container.
When is it required to wash your hands?
After contact with fluids, immediately after removing gloves, and between patients.
When is respiratory hygiene necessary? When is it necessary?
For any patient that has a cough.
At point of contact.
When are standard precautions necessary?
FOR EVERYONE.
What bodily secretion is not considered dangerous?
Sweat
True or false, you should take precautions when touching mucus membranes.
True.
What part of your hand should be used when palpating?
The palmar side of your fingers/hand
What is the correct order of examination?
Inspect
Palpate
Percussion
Auscultation
What are the four Cs?
Courtesy
Comfort
Connection
Confirmation
