patient chart Flashcards

1
Q

These are vital tools for healthcare providers. They ensure the safe and effective care of patients by providing a comprehensive overview of their medical history, allergies, current medications, and other important information.

A

Patient Chart and Medication Profiles

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2
Q

Patient Demographics

A

• Patient Name
• Date of Birth
• Gender
• Contact Informatiob

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3
Q

The patient’s full legal name, typically used to identify and address them during healthcare interactions.

A

Patient Name

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4
Q

The patient’s birthdate, often used for age calculation and medical record organization.

A

Date of Birth

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5
Q

The patient’s self-identified gender, including male, female, or other options, vital for understanding and respecting individual preferences.

A

Gender

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6
Q

Essential for communication, this includes phone numbers, email addresses, and residential addresses, ensuring proper reach for appointment scheduling, test results, and other updates.

A

Contact Information

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7
Q

These are fundamental measurements that reflect a patient’s overall health status. They are routinely monitored during clinical encounters to identify potential issues.

A

Vital signs

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8
Q

Vital signs include:

A

Temperature (98.6 F or 37 C)
Pulse (60-100 bpm)
Blood Pressure (120/80 mmHg)
Respiratory Rate (12-20 breaths pm)
Oxygen Saturation (95-100%)

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9
Q

Medical History

A

Past Medical Conditions
Family Medical History
Social History
Immunizations

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10
Q

Includes any previous illnesses, surgeries, or chronic health issues. This provides a comprehensive view of the patient’s medical history.

A

Past Medical Conditions

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11
Q

Details about diseases or conditions that run in the patient’s family, such as diabetes or heart disease. This helps identify potential risk factors.

A

Family Medical History

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12
Q

Includes details about the patient’s lifestyle, including smoking, alcohol consumption, and drug use. This information helps assess potential health risks.

A

Social History

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13
Q

A record of all vaccinations the patient has received, including dates and types of vaccines. This helps track immunization status and ensure complete coverage.

A

Immunizations

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14
Q

This section documents any known allergies the patient has to medications, foods, or other substances.

A

Recorded Allergies

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15
Q

It is conducted to determine the severity and potential triggers of each allergy.

A

comprehensive allergy assessment

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16
Q

Current Medications listed in patient charts

A

prescription medications
otc medications
herbal remedies

17
Q

It refers to the amount of medication administered

18
Q

it indicates how often the medication is given

19
Q

Knowing when a patient started and stopped taking a medication is crucial for understanding their treatment history.

This information helps healthcare providers track the effectiveness of a medication and identify any potential side effects or interactions that may have occurred during the course of treatment.

20
Q

A medication interaction occurs when two or more medications are taken together, and their effects combine in a way that can be harmful.

A

Potential Conflicts

21
Q

It is crucial for healthcare professionals and patients to monitor for potential interactions, especially when multiple medications are prescribed.

A

Monitoring for Interactions

22
Q

The severity of a medication interaction can range from mild side effects to life-threatening complications.

A

Severity of Effects

23
Q

Interactions can also occur between medications and certain foods, beverages, or supplements.

A

Drug-Food Interactions

24
Q

Regular monitoring for side effects is crucial. Patients should report any unusual symptoms or worsening conditions to their healthcare providers.

25
Factors Affecting Adherence
Side effects Complexity of regimen Cost of medication Lack of understanding Forgetfulness
26
Consistent medication intake is crucial for effective treatment and achieving desired health outcomes. Adherence ensures proper drug levels in the body, minimizing adverse events and maximizing therapeutic benefits.
27
Medication Refill History
Date and Time Medication Name Dosage and Frequency Quantity Dispensed
28
It shows the test results for the patient. The results are organized by test type. The chart can be used to monitor the patient's health over time.
Laboratory Results Chart
29
It plays a crucial role in identifying the underlying cause of a patient's health concerns. These tests provide valuable insights into the body's internal structures and functions, allowing healthcare providers to make accurate diagnoses and develop tailored treatment plans.
Imaging and diagnostic tests
30
Common imaging tests include:
X-rays, CT scans, MRI scans, and ultrasound
31
Care Plan and Treatment Goals
Collaborativr Care Treatment Timeline Progress Monitoring
32
The care plan is developed by the patient and healthcare team to address individual needs and goals.
Collaborative Care
33
The timeline includes medication schedules, appointments, and monitoring procedures.
Treatment Timeline
34
Regular assessments track progress and adjust the plan as needed to achieve optimal outcomes.
Progress Monitoring