patient interview Flashcards
Who developed HIPAA
Depart. of Health and Human Services (enacted 1996)
What is HIPAA for?
Designed to provide privacy standards to protect patients medical records and other health information provided to health plans, doctors, hospitals, and other healthcare providers
What does HIPAA do for the patient?
Provides patients with access to their medical records and more control over how their personal health information is used and disclosed
What is anothers for indentification sheet?
registration sheet
what information does the consent form have?
Patient Name & Date
Name and Description of Surgery
Indication for Surgery
Risks & Benefits of Procedure
Alternatives to Procedure
Patient’s Signature, printed name, date, and time/Surgeon’s signature
*Patient must be competent to make medical decisions
what’s the difference between a basic H&P and a consult note?
Consult done by a subspecialty
What does S.O.A.P. stand for?
Subjective
Objective
Assessment
Plan
What is the difference between subjective and objective?
subjective - what patient tells you
objective - what you find on exam
What must the physicians orders contain?
- date/time
- order being given
- physician’s signature
what is normal range for blood pressure?
90/60 - 120/80 mmHg
what is normal range for heart rate?
60 - 100 bpm
what is normal respiratory rate?
12-20 breaths/min
What is normal temperature?
97.8 - 99.1 F (36.5 - 37.2 C)
What is a normal pusle ox range?
95 - 100 %
Define systolic pressure
pressure exerted on the walls of the arteries during heart contraction (systole)