Lecture 4-5: Interview Basics Flashcards
What are the laws of personal space?
Intimate: 1.5 feet away
Personal: 4 feet away
Social: 10 feet away
What are some active listening skills?
Smile Eye Contact Posture Mirroring Minimize Distraction
At what grade level should patient education material be written at?
6th grade level
What is a Patient Centered Medical Home (PCMH)?
Model of care that allows patient and sometimes their families be a partner in the treatment plan
What does SOAP note stand for?
Subjective: what the patient says about the history
Objective: physical findings (physical exam, structural findings, laboratory, and radiology data)
Assessment: Potential Diagnosis
Plan: What a clinician decides, How to treat, and any OMT performed
What is included in Subjective part of SOAP Note?
Chief Complain History of Present Illness (HPI) Review of System (ROS) Past Medical History (PMH) Past Surgical History (PSH) Medications (Meds) Allergies (All) Family History (FH) Social History (SH)
What is included in Objective part of SOAP Note?
Physical Findings (including Vital signs)
Laboratory Data
Radiology Data
What is included in Assessment part of SOAP Note?
Differential Diagnosis listed in most likely to least likely
-assessment not always diagnosis
What is included in Plan part of SOAP Note?
What clinician plants to do about problems identified in assessment
What does the mnemonic OLD CAAARTS stand for?
Onset: when did it start Location Duration: constant or comes and goes Character Alleviating Factors: Anything else about CC Aggravating Factors Associated Symptoms Radiation Timing: when is symptom more likely to happen Severity: Scale of 0-10
What is included in PMH?
Hospital Stays
ER Visits
Chronic Conditions/Illnesses
What is included in PSH?
Any operations (including Cesarean sections) -Dental surgeries and sutures don't count
What is included in medication?
Prescription Drugs
OTC Drugs
Supplements
What is included in allergies?
Meds, Environmental, Food
-include reaction
What is included in family history?
Parents, siblings, kids
-chronic conditions, cancers, mental health issues, etc
What does the mnemonic FED TACOS cover in social history?
Food Exercise Drugs Tobacco Alcohol Caffeine Occupation Spirituality Sexual Relationships
Which components of social history must be covered in every encounter?
Drugs: Quantity, frequency, route of administration
Tobacco: Quantity, duratio, pack years,
Alcohol
The CDC recommends how many minutes of moderate activity?
150 minutes
What does the USPSTF recommend in men ages 65-75 who have ever smoked?
Screening for Abdominal Aortic Aneurysm with ultrasonography
What does the USPSTF recommend for adults ages 55-80 who have a 30 pack year smoking history and has currently smoked or quit in the past 15 years?
Lung Cancer Screening
What is a pack year?
Number of packs smoked per day x number of years smoked
Example: If a person smokes 1.5 packs a day for 40 years, pack year is 60.
What are CAGE questions?
Screening for Alcohol Usage
- Has anyone suggested you CUT BACK?
- Are you ANNOYED when people talk to you about your drinking?
- Do you ever feel GUILTY about your drinking?
- EYE OPENER: Do you ever need a drink in the morning to steady your nerves?
For women and adults over the age of 65, what is considered low-risk drinking?
No more than 3 drinks a day
No more than 7 drinks per week
For men, what is considered low-risk drinking?
No more than 4 drinks a day
No more than 14 drinks per week
What is considered a drink?
Beer: 12 oz
Wine: 5 oz
Liquor: 1 ounce
What does the mnemonic FICA cover in spirituality and religion?
F: Faith and belief
I: Importance
C: Community
A: Address in care
What are good questions to ask about safety?
Seatbelt Use Helmet Use Car Seats Fences Medication Storage Immunizations
What does the mnemonic SAFE cover in domestic violence?
S: Stress/Safety
A: Afraid/Abused
F: Friends/Family
E: Emergency Plan
