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.
Past health hx
Childhood illnesses
Accidents or injuries
Serious chronic illnesses
Hospitalizations
Operations
Obstetrical hx
Immunizations
Most recent exam date
Allergies
Medications
Family health history
Ages and health, or ages and cause of death for family. Ask about close family members and prolonged contact, etc.
Functional assessment components
Self concept/self esteem
Activity & mobility
Sleep and rest
Nutrition & elimination
Interpersonal relationships
Spiritual resources
Coping & stress management
Tobacco use
Substance use
Environmental hazards
Intimate partner violence
Occupational health
Children past health hx
Prenatal status
Labour and delivery
Postnatal status
Childhood illnesses
Serious accident or injury
Serious or chronic illness
Operations or hospitalization
Immunization
Allergies
Medication
Child developmental hx
Growth
Milestones
Current development
Deontological imperatives
Moral acts that are obligatory regardless of their consequence to human welfare. Imperative implies a command.
Beneficence
Quality or state of doing or producing good.
Moral duty to promote the course of action they believe is in best interest of the patient.
Non-maleficence
The obligation to do no harm to the patient.
Utilitarianism
Determines right from wrong by focusing on outcomes.
Most ethical choice is the one that will produce the greatest good for the greatest number.
