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Medical Assistant - Chapter 21 > KINNS MEDICAL HISTORY CHPT 21 > Flashcards

KINNS MEDICAL HISTORY CHPT 21 Flashcards

1
Q

What is a healthy state

A

More than absence of disease

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2
Q

What is a holistic perspective

A

Method of analyzing all factors that may contribute to the dev disease

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3
Q

First step in treating disease process

A

Step 1 in treating disease process is medical diagnosis

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4
Q

Differential dx

A

Considers which one of several dz may be producing sx

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5
Q

2nd step in treating disease

A

Provider considers all factors and comes up with working dx

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6
Q

Clinical Dx

A

Aka working dx

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7
Q

Aka Working dx

A

After hx, comprehensive physical exam, before lab tests, x rays or other dx testing is done

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8
Q

Final dx

A

Determined after all dx studies completed

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9
Q

When does pt care begin

A

When they contact the office

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10
Q

Collecting the history information

A

New pt completes health hx form (self history)

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11
Q

Taking hx

A

In private area, free of distractions

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12
Q

What is included in history information

A

Chief complaint (CC) purpose of the pts visit

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13
Q

Provider and Hx

A

May take hx on first visit

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14
Q

EHR

A

Incorp pts hx and physical exam directly in health record

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15
Q

Components of med history

A

Database; record of the pts demographic info

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16
Q

What is the Chief Complaing

A

Chief Complaint: purpose of visit

17
Q

What is in the History of Present Illness

A

History of Present Illness (HPI)

18
Q

What is in the Past History

A

Past History (PH) or Past Medical HIstory (PMH)

19
Q

What is considered OTC

A

OTC Over the Counter Medications

20
Q

What is in the Family History

A

Family HIstory (FH)- details about pt parents siblings

21
Q

What is in Social History

A

Social History - info about lifestyle

22
Q

What is in Systems Review

A

Systems Review (SR) or Review of Symptoms (ROS)

23
Q

Meaningful Use

A

Providers required to collect info on allergies, pt hx, safe at home, alcohol use

24
Q

Allergy documentation

A

Each office has policy on how

25
Q

boundaries

A

Pts not friends

26
Q

self-boundaries

A

Professional boundaries

27
Q

Diverse pt pop

A

Age, culture, religion , phys qualities (deaf, hard of hearing)

28
Q

empathy

A

Caring therapeutic env

29
Q

Value system

A

Value sys shapes how we respond to diversity

30
Q

Personal biases and prejudice

A

Barriers to therapeutic communication

31
Q

CC

A

CHIEF COMPLAINT

32
Q

VS

A

Vital Signs (VS)

33
Q

UCD, UCHD

A

USUAL CHILDHOOD DISEASES

34
Q

HPI

A

History of Present Illness (HPI)

35
Q

PH OR PMH

A

Past History (PH) or Past Medical HIstory (PMH)

36
Q

OTC

A

OTC Over the Counter Medications

37
Q

SR, ROS

A

Systems Review (SR) or Review of Symptoms (ROS)

Medical Assistant - Chapter 21 (4 decks)

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