Health Assessment Flashcards
What kind of information is collected during an interview?
subective
SBAR
Situation
Background
Assessment
Recommendation
What should the distance be between you and your patient during the interview?
4-5 ft
Open-ended questions
used when you want a narrative response, used to introduce a new section
9 types of verbal responses
facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary
What is an example of interpretation?
an inference made about the patients condition, you could be wrong but the patient will correct you
What is said about touch in an interview?
Do not touch during the interview unless you know the person well enough and know how it will be interpreted.
When interviewing for an infant, how would you communicate with the infant?
nonverbal cues
When interviewing an adolescent what areas of verbal response should be avoided?
Silence and Reflective
How might you help the older patient handle the long interview process?
Let him take some questions home, break up the interview process into more that one visit
What is a poly-drug user?
Uses more than one drug
What is a database?
history combined with objective data from the physical examination and lab studies
What is biographic data?
name, address, DOB, etc.
What 3 questions do you ask about the source of history?
- Who provided the information?
- How reliable was the source?
- Any special circumstances?
What is the “reason for seeking care?”
In the patients own words a description of the reason they are visiting (state one or two symptoms or signs)
How do you document present health or history of present illness in an ill person?
A chronologic record of the reason for seeking care, from the first time the first symptom appeared until now.
P,Q,R,S,T,U
provocative or palliative, quality or quantity, region or radiation, severity scale, timing, understand patients perception.
How would you ask about the general health in an older adult vs a younger adult?
Only need to know that past 5 years in an older adult
What is a mental disorder?
when a persons response is much greater than the expected reaction to the traumatic event
SOAP
subjective, objective, assessment, plan
Organic disorder
A brain disease with a known specific caused
What is an example of a psychiatric mental illness?
anxiety, schizophrenia
4 main headings of mental status assessment
Appearance, Behavior, Cognition, Thought Process
Aphasia
the impairment of language ability due to brain damage
