Foundations of Health Assessment Flashcards
Why is the history so important?
60-80% of diagnoses can be made by history alone
2 parts of medical history
presenting concern
past history
Types of histories
- Comprehensive - aka Complete, Expanded; for new patients
- Focused - aka Problem oriented or Basic; for established patients and/or urgent/acute care
- Inventory - Related to “complete” note but not as detailed
- Interim - chronicles events between visits
SOAP note
S-subjective; what patient tells you
O-objective; your findings
A-assessment
P-plan
Question types
open-ended; used for general information seeking
direct or closed; for seeking specific facts
Methods to assess patient-clinician communication
- “Ask me 3”
- Teach back - patient explains in their own words
- 4 C’s; call, cause, concern, cope
SIG E CAPS
S-sleep changes I-interest (loss of) G-guilt E-energy (lack of) C-cognition/concentration A-appetite P-psychomotor S-suicide
Histories to use for alcohol
CAGE
TACE
MAST
ACEDIT
Histories to use for illicit drugs
CAGE CRAFFT (adolescents)
CAGE
C-concern (about your drinking)
A-annoyed (criticism of your drinking?)
G-guilty about drinking?
E-Eye opener?
TACE
T-Take – how many drinks does it take?
A-annoyed
C-cut – feel that you should cut down on drinking?
E-eye opener?
CRAFFT
C-car; ever been in a car driven by someone under the influence?
R-relax; use or take to relax?
A-alone; use alone?
F-forget; forget what you do while using?
F-family/friend; someone ask you to cut back?
T-trouble; gotten into trouble?
HITS
Used for domestic violence H-hurt you physically? I-insult or talk down to you? T-threaten physical harm? S-scream or curse at you?
What goes in ‘S’ part of SOAP note?
Information
Absence or presence of symptoms
Pt. offered information
What goes in ‘O’ part of note?
Findings
Direct observations
What to avoid in writing a SOAP note?
words like “good,” “normal”
documenting things you did not do (excluding vitals)
blank lines
white-out
Symptom vs. sign
Symptom - manifestation of disease of which the patient is usually aware
Sign - observation or palpable phenomenon associated with a given disorder
Sections in Subjective section
CC HPI (history of present illness) with PROS MEDS allergies PMHx PSHx FMHx SOCHx ROS
CC
Chief complaint; what they are being seen for
Placed in quotation marks; simple statement “headache”
HPI
Tells the story of the CC
Onset, location, duration, character, aggravation, alleviating, radiation, timing, severity, etc.
PROS
Pertinent review of symptoms
Ask questions about other things related to the CC
MEDS
List all medications
In SOAP note with no punctuation
3 sections: Rx, OTC, herbal/vitamins
name, dosage, number of tablets, route, frequency, last dose taken
Allergies
3 sections: drug, food, environment
List the reaction to the allergy (rash, etc.)
PMHx
Past Medical History medical problems and illnesses childhood illnesses immunizations THE CHADS - list any positives before negatives
THE CHADS
Goes in PMHx T-Thyroid disease H-hypertension E-emphysema C-cancer H-heart disease A-asthma D-diabetes S-stroke
PSHx
Past surgical history
type of history, reason for surgery, date, hospital, complications
FMHx
Family history
Parents, siblings, kids
age, alive or deceased/cause of death
grandparents (for a ped history)
SOCHx
Social history occupation, relationship status habits: tobacco alochol, drugs, diet, caffeine sexual history travel military exercise
ROS
Review of symptoms (general)
Ask about all body systems
Parts of sports physical
medical history
physical exam
clearance
Major reasons for sports disqualifications
dizziness with exercise asthma history unfavorable BMI BP elevation visual issues heart murmur musculoskeletal abnormality
Non-qualified, no exceptions (for sports)
CARDITIS
Diarrhea
FEVER
Structural heart disease
Qualified or qualified with explanation
asthma congenital heart disease diabetes eating disorders hep or HIV loss of eye malabsorption syndromes obesity seizures sickle cell
Female athlete triad
disordered eating
amenorrhea (loss of period)
osteoporosis
