Module 2 Flashcards
Subjective data
What the patient says about themselves
Open-ended questions
Asks for narrative information. Allows patient to explain in their own words
Closed or direct questions
Asks for specific information. Generally elicit a yes or no answer
Facilitation or general leads
Encourages patient to say more. (IE go on)
Silence
Allowance for thinking silence without filling the space.
Reflection
Echoes the patients word. Focuses on a specific phrase to help patient continue to answer. Also can express feeling behind patients words.
Empathy
Accepts patients feelings and builds rapport. Justifies thoughts and feelings.
Clarification
Used to seek clarification for confusing or ambiguous words or descriptions. Also can be used to summarize patients words or focus on a discrepancy
Interpretation
Based on your own inference or conclusions of the patients narrative. Links events, makes associations, or implies cause. Also describes patients feelings. Allows patient to correct you.
Explanation
You give the patient the information. Share factual and objective data.
Summary
Final review of your understanding of what the patient said.
Objective data
Data from the physical examination and lab studies.
Biographical data
Pt self identifies: name, age, DOB, birthplace, other recent countries of residence, sex, gender, relationship, usual and current daily activities
Reason for seeking care
Brief, spontaneous statement in the patients own words that describes reason for visit.
Current health history or history of current illness.
Short statement about general state of health for the well patient.
Chronological record of the reason for seeking care from the time of onset to now.
