History Taking Flashcards
Chief complaint
Primary medical problem as defined by the patient.
- Focuses the clinical history towards the single most important issue
Chronology
Time element of the history, usually included the onset, duration, frequency and course of the symptoms
Clinical history
Information available regarding a patient’s condition
What is a clinical history comprised of?
Localization, Quality, Quantity, Chronology, Setting, Aggravating or Alleviating factors, and associated manifestations
Leading questions
Undesirable method of questioning; provides information that may direct answers toward a suggested symptom
Localization
The exact area of the complaint
Objective
Perceptible to the external senses
Quality
Description of the character of symptoms; color, quantity and consistency of blood or size or number of lumps/lesions
Subjective
Pertaining to or perceived only by the affected individual and not perceptible to the senses
What are the 3 main roles of the radiographer?
- Obtain a clinical history to assist the radiologist in diagnosing
- To record information on the requisition
- Check all information on the requisition for accuracy
What is the x-ray requisition?
The formal order for a diagnostic procedure and is a medical legal document
What information is included on a X-ray requisition?
- Patient Name
- Sex of patient
- Diagnosis (Dx) and pertinent clinical history (Hx)
- Date of exam and date when arrived
- Date of Birth (DOB)
- Signature of the requesting physician
- Pregnancy status and LMP (last menstrual period)
- Medical record number and insurance information
How to greet a patient?
- First introduce yourself and explain you’re the radiographer
- Ask the patient their name and check wristband for inpatient
- Always address patient by their last name, Mr or Mrs
What are the important features of interviewing a patient?
- Speaking slowly and clearly
- Listening to the patient
- Maintaining eye contact
- Using language the patient can understand
- Only asking one question at a time
What are patient interview Do’s?
- Ask open-ended, non-leading questions - to let the patient tell their story
- Facilitation (nodding, saying yes or no) - to encourage elaboration
- Silence (giving patient time to remember) - facilitates accuracy and elaboration
- Probing questions (to focus the interview)
- Repetition (rewording) clarifies information
- Summarization (condensing) verifies accuracy
What are patient interviews Don’ts?
- Do not ask personal questions
What are features of Objective Data?
- Perceptible to the senses
- Signs that can be seen, heard, felt
- Able to be measured
- Often physiologic
What are features of subjective data?
- Patient feeling
- Pain level
- Attitude
- Opinion of the observer
- Subject to interpretation
What are elements of a clinical history?
- Chief complaint
What are the sacred seven?
- Localization
- Chronology
- Quality
- Severity
- Onset
- Aggravating or alleviating factors
- Associated manifestations
Severity
The intensity and quantity of the symptom
Onset
When the symptoms began
Aggravating or alleviating factors
What makes the symptoms worse or better
Associated manifestations
Any other symptoms that accompany the chief complaint
What is informed consent?
Also called valid consent, and is a full explanation of the procedure including risks and benefits
What are the conditions for informed consent?
- patient must be mentally competent and of legal aged to make an informed consent
- consent must be voluntary
- consent must be signed by the parent or guardian
- explanation of the procedure must be in terms that the patient understands
What is implied consent?
Provides care when the patient is unconscious, and is based on the assumption that the patient would approve if conscious
What is simple consent?
Patient agrees with no explanation
What is confidentiality?
To hold in strict confidence any information learned about a patient in the course of medical treatment
What is HIPAA?
The federal health insurance portability and accountability act of 1996
What is the primary goal of HIPAA?
To make it easier to keep health insurance, protect the confidentiality and security of healthcare information and help the industry control admin costs
What is privacy?
The right to be left alone, the right of a person to be free of unwanted publicity
What is access to information?
A patient has the right to access their medical reports/information
What is a living will?
A document that allows the patient to state their wishes for end of life care, it has no power after death
What is a health care proxy?
Patient names a person to be their spokesperson if they become incapacitated
What is research participation?
A patient has the right to decide whether or not they want to participate in reasearch
What is duty?
What should have been done
What is breach?
Deviation from duty
What are examples of invasion of privacy?
- Violation of confidentiality
- Improperly touching a patient
- Taking radiographs without patient’s permission
What is a violation of professional conduct?
Conduct that causes the patient to fear (verbally threatening more films, exams, etc)
What is the rule of personal responsibility?
Individuals are responsible for their own actions
What patient assessment should be done before imaging?
- Identify the patient
- Confirm age and DOB
- Confirm the correct exam has been ordered
- Record a brief clinical HX
- Access the patient’s general condition and ability to cooperate
- Check pregnancy status by verifying LMP
- Check for allergies if applicable
- Check for metal artifacts
What patient assessment should be done during imaging?
- continuously monitoring the patient’s health and vital signs
- reassure the patient throughout the procedure
What patient assessment should be done after imaging?
- record any problems or concerns on the requisition
- discuss with the patient what will happen after the exam
- list any modifications to the procedure
What to do when a patient refuses an x-ray exam?
- Try and explain why the doctor ordered the exam
- Explain the procedure to the patient and how it will benefit them by helping the doctor make a diagnosis
How should data on an x-ray be validated?
- Radiographer should initial or sign any information that they added to the request or patient record.
- Also mark the films with lead markers that identify who took the radiographs
AP
Anteroposterior
PA
Posteroanterior
LAT
Lateral
OBL
Oblique
CXR
Chest x-ray
BP
Blood Pressure
Abd
Abdomen
ABX
Abdominal x-ray
KUB
Kidneys, ureters and bladder
HX
History
FX
Fracture
MVA
Motor Vehicle Accident
GSW
Gun shot wound
DOB
Date of Birth
R or RT
Right
L or LT
Left
c/o
complains of
LMP
Last menstrual period
PE
Physical Exam
Post op
After surgery
Pre op
Before surgery
pt or PT
patient
stat or STAT
immediately
ARDS
acute respiratory distress syndrome
CA
cancer
R/O
rule out
