Patient Interviewing Flashcards
What is Patient Centered Interviewing?
Centered on the patients needs and engages the patient on a higher level
Patient has an active role, is a partner of the treatment plan, collaborates with the physician, and quality of life is at the center of care
What is physician centered interviewing?
Traditional way of taking a history; more of a list focused interview
Patient is interrupted constantly as it is the physician controlling the conversation
Describe the basic format of a SOAP note
S=subjective: what you learn by taking the patients history
O=Objective; physical exam findings based on labs, radiology, and structural findings
A=assessment; what you think is going on
P=Plan; what you and the patient agree to do; OMT is included here
What are the aspects that are including in the S section of the SOAP note?
CC HPI ROS PMH PSH Meds Allergies FH SH
What is included in the O section of the SOAP note?
PE findings
Labs
Radiology
What is included in the A portion of the SOAP note?
Basic description
Diagnosis
Differential Diagnoses
What is included in the P portion of the SOAP note?
What the doctor plans to do for the problems that are identified in the assessment
What is OOOLDCAAARTS
Onset (when, what doing, had before?) Location Duration Character Alleviating Aggravating Associated Radiation Timing Severity
What are the most important things to ask regarding the patients medications
- Prescriptions
- OTC
- Supplements
Record the Dose and timing of the medications
What are the most important things to ask regarding the Allergies of the patient?
- Medications
- Environmental
- Food
Ask them what happens when they take the medication
What is FEDTACOS
Food Exercise Diet Tobacco Alcohol Caffeine Occupation Speirtuality, Sex, Safety
What does the CDC recommend about adult exercise
150 minutes per week of moderate activity and strength training 2 days a week
What does the CDC recommend about children and adolescent exercise?
1 hour or more of daily physical activity
What are the CAGE questions when asked about alcohol?
- Has anyone suggested that you Cut back
- Are you ever annoyed when people talk about your drinking
- Do you ever feel guilty about your drinking?
- Do you need a drink in the morning to steady your nerves?
C-Cut back
A-Annoyed
G-Guilty
E-Ease your nerves
What are the NIAAA safe ranges of alcohol consumption for women and those over 65?
No more than 3 drinks a day and no more than 7 drinks a week
What are the NIAAA safe ranges of alcohol consumption for men?
No more than 4 drinks on a single day and no more than 14 drinks a week
When are AUDIT screenings used?
For screening for an unhealthy use of alcohol, tobacco, and the drugs
What is “a drink”?
- Wine
- Beer
- Liquor
- 5 ounces of wine
- 12 ounces of beer
- 1 oz of liquor
Describe FICA and how it relates to spirituality
Faith and belief
Importance
Community
Address in care or assessment and plan
Why do we obtain an ROS?
Identify co-existing conditions
Build your case medically and legally
Accurate billing information
Which of the following are associated with the medical model of patient interviews (check all that apply)? a. Care is quality of life centered b. Patient is passive c/ Physician talks more and cares less d. Patients role is active e. Patient is recipient of treatment
A and D
What is a differential diagnosis?
a. A statement of one thing the physician thinks the problem is based on subjective and objective data
b. A list of considerations for what the problem might be based on subjective and objective data
c. An element to be included in the subjective portion of the SOAP note
d. A reminder that everybody has problems, but the patient’s may be different than the physician’s
e. An element that is patient-generated
B
Which of the following is a step in the patient centered interaction in your text?
a. Open with physician-centered agenda
b. Set the stage for the interview
c. Asking of closed-ended questions
d. Leading the patient in prayer
e. Document effectively
B
Which of the following is true about past medical History?
a. It includes only diseases or illness diagnosed by a health care provider
b. It does not include problems the patient has currently
c. Includes everything that has happened in the past and has completely resolved, including common colds
d. May be difficult to elicit
e. Only needs to be obtained at the first encounter with a patient
B
