patient interview Flashcards

1
Q

Who developed HIPAA

A

Depart. of Health and Human Services (enacted 1996)

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2
Q

What is HIPAA for?

A

Designed to provide privacy standards to protect patients medical records and other health information provided to health plans, doctors, hospitals, and other healthcare providers

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3
Q

What does HIPAA do for the patient?

A

Provides patients with access to their medical records and more control over how their personal health information is used and disclosed

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4
Q

What is anothers for indentification sheet?

A

registration sheet

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5
Q

what information does the consent form have?

A

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

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6
Q

what’s the difference between a basic H&P and a consult note?

A

Consult done by a subspecialty

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7
Q

What does S.O.A.P. stand for?

A

Subjective
Objective
Assessment
Plan

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8
Q

What is the difference between subjective and objective?

A

subjective - what patient tells you

objective - what you find on exam

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9
Q

What must the physicians orders contain?

A
  1. date/time
  2. order being given
  3. physician’s signature
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10
Q

what is normal range for blood pressure?

A

90/60 - 120/80 mmHg

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11
Q

what is normal range for heart rate?

A

60 - 100 bpm

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12
Q

what is normal respiratory rate?

A

12-20 breaths/min

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13
Q

What is normal temperature?

A

97.8 - 99.1 F (36.5 - 37.2 C)

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14
Q

What is a normal pusle ox range?

A

95 - 100 %

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15
Q

Define systolic pressure

A

pressure exerted on the walls of the arteries during heart contraction (systole)

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16
Q

Define diastolic pressure

A

pressure exerted on the walls of the arteries during heart relaxation (diastole)

17
Q

Mean arterial pressure (MAP) is a.k.a. ?

A

perfusion pressure

1/3(S-D) + D

18
Q

what is ideal MAP?

A

> 60 mmHg to perfuse organs

>70 mmHg to perfuse organs (HTN pt)

19
Q

what B/P range is stage 2 HTN?

A

S > 160 or D > 100

20
Q

What B/P range is stage 1 HTN?

A

140 - 159 / 90 - 99

21
Q

What is considered prehypertension

A

120-139 / 80-89

22
Q

True or false. An athlete’s resting heart rate can be in 40s (bpm)

A

true

23
Q

how do you take radial pulse?

A
  1. feel rate for 15 sec

2. multiply x 4

24
Q

what is the term for deep breathing?

A

hyperpnea

25
Q

what is the term for shallow breahting?

A

hypopea

26
Q

What is the term for apnea alternating with tachypnea?

A

cheyne - stokes

27
Q

What is the term for deep labored breathing seen with metabolic acidosis?

A

kussmaul’s breathing

28
Q

If the oral temp is 98.6 what is an estimate for the axilla temp? rectal temp?

A

a. 97.6

b. 99.6

29
Q

what are the sources for core termp. measurements?

A

bladder
esophogeal
rectal

30
Q

how does the pulse ox work?

A

measures saturation of hemoglobin
light of 2 different wavelenths passes through patient to photodetector
changing absorbance at each of the wavelengths is measured allowing determination of the absorbances due to the pulsing of arterial blood alone

31
Q

what does CAGE stand for?

A

Cut down
Annoyed
Guilty
Eye Opener

32
Q

what are Kublar Ross’ s responses to death

A
denial & isolation
anger
bargaining
depression
acceptance
33
Q

Define beneficence

A

“do good” for the patient

34
Q

define nonmaleficence

A

first do no harm