Patient Interview Flashcards
HIPAA
health insurance portability and accountability act 1996
Purpose of HIPAA
provide privacy standards to protect patients and medical records and other health information.
Who developed HIPAA?
Department of health and human services.
Most important part of the patient chart?
Admission history & physical
Chief complaint, mentioned where
Admissions history & H&P
SOAP
subjective, objective, assessment, plan
Stage 1 HTN
140-159 systolic 90-99
CAGE questions
cut down, annoyed, guilty, eye-opener
Kubler-Ross 5 stages in a person’s response to death
denial & isolation, bargaining, depression or sadness, acceptance
TID
Thrice per day and continue to pray
QID
Four per day to take the pain away
BID
twice per day as the doctor say
q#h
every # hours
MAP to perfuse organs
> 60mmhg
MAP to perfuse organs in HTN patient
> 70 mmhg
axillary temperature accuracy
1c lower than oral
rectal temp accuracy
.4-.5 c higher than oral. bitter to the taste
Source of obtaining core temps
pulmonary artery > distal esophagus > bladder > nasopharyngeal > rectal
For all medications
dose, route, frequency/scheduled vs pm
Alcohol dependence use
7.50%
illicit drug dependence/use
2.70%
3 dimensions of cultural competence
self-awareness, respectful communication, collaborative partnerships
pc
after food
ou
both eyes
os
left eye
od
right eye (derecha in spanish helps me remember this one)
qod
every other day
ac
before meals
