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)
Define diastolic pressure
pressure exerted on the walls of the arteries during heart relaxation (diastole)
Mean arterial pressure (MAP) is a.k.a. ?
perfusion pressure
1/3(S-D) + D
what is ideal MAP?
> 60 mmHg to perfuse organs
>70 mmHg to perfuse organs (HTN pt)
what B/P range is stage 2 HTN?
S > 160 or D > 100
What B/P range is stage 1 HTN?
140 - 159 / 90 - 99
What is considered prehypertension
120-139 / 80-89
True or false. An athlete’s resting heart rate can be in 40s (bpm)
true
how do you take radial pulse?
- feel rate for 15 sec
2. multiply x 4
what is the term for deep breathing?
hyperpnea
what is the term for shallow breahting?
hypopea
What is the term for apnea alternating with tachypnea?
cheyne - stokes
What is the term for deep labored breathing seen with metabolic acidosis?
kussmaul’s breathing
If the oral temp is 98.6 what is an estimate for the axilla temp? rectal temp?
a. 97.6
b. 99.6
what are the sources for core termp. measurements?
bladder
esophogeal
rectal
how does the pulse ox work?
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
what does CAGE stand for?
Cut down
Annoyed
Guilty
Eye Opener
what are Kublar Ross’ s responses to death
denial & isolation anger bargaining depression acceptance
Define beneficence
“do good” for the patient
define nonmaleficence
first do no harm