History Taking

Question 1

what is the purpose of history taking?

Answer 1

collect subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment

Question 2

this type of assessment gathers a full history of the patient’s health status and current problems, as well as provides health promotion and risk reduction education.

Answer 2

initial comprehensive assessment

Question 3

this type of assessment is a follow-up or update.

Answer 3

ongoing or partial assessment

Question 4

this type of assessment assesses a particular problem.

Answer 4

focused or problem-oriented assessment

Question 5

this type of assessment focuses on an emergent problem with a systematic prioritization.

Answer 5

emergency assessment

Question 6

what the person tells you about themselves

Answer 6

subjective data

Question 7

what you observe or measure

Answer 7

objective data

Question 8

what are the steps of health assessment?

Answer 8

1. collection of subjective data. 2. collection of objective data. 3. validation of data with physical exam. 4. documentation of findings.

Question 9

what type of atmosphere do you want to create with a patient?

Answer 9

accepting, non-judgmental, empowering, supportive, understanding

Question 10

what are some ways nonverbal communication is displayed?

Answer 10

appearance, demeanor, facial expression, posture, attitude, silence, listening, touch

Question 11

what are some ways to make your patient comfortable with the EHR?

Answer 11

integrate typing around your patient’s needs, tell your patient what you are doing, encourage participation, and look at your patient

Question 12

“why are you here?”

Answer 12

open-ended question

Question 13

“are you in pain?”

Answer 13

close-ended question

Question 14

“are you telling me that..?”

Answer 14

rephrasing

Question 15

sequence of assessment

Answer 15

biographical data, chief complaint, HPI, PMH, family history, social history, review of systems, functional assessment

Question 16

what are the seven dimensions of a symptoms?

Answer 16

location, quality, quantitative aspects, chronology, setting, aggravating and alleviating factors, related symptoms.

Question 17

why are assessments important?

Answer 17

facilitate communication, provide database for all providers, easy retrieval of information

Question 18

brief description of perceived problem in patient’s own words

Answer 18

chief complaint

Question 19

chronological course of events using the 7 dimensions symptoms analysis

Answer 19

HPI

Question 20

childhood/current illnesses, immunizations, surgery, hospitalizations, serious injuries, current meds, allergies, transfusions, obstetric history, last exams

Answer 20

PMH

Question 21

age of parents and diseases, may include genogram

Answer 21

family history

Question 22

smoking, drugs, alcohol, who you live with, occupation, exercise, sleep, stress management, nutrition

Answer 22

social history

Question 23

organ system review, includes health promotion

Answer 23

review of systems

Question 24

SOAP note includes:

Answer 24

subjective, objective, assessment, plan

Question 25

objective data uses:

Answer 25

inspection, palpation, percussion, auscultation