PSH, Medication, Allergies, FHx

Question 1

How to document PSHx

Answer 1

Chronological order
*most recent to oldest
1. What, when, who, where
2. Outcome
3. Any complications

Question 2

How to document medications

Answer 2

1. Prescribed
2. OTC
   MUSTS HAVE
   
   1. Name
   2. Dose
   3. Route
   4. Frequency
      **Always ask why

Question 3

How do document allergies

Answer 3

1. What allergy
2. What happens during the allergic reaction
3. Determine if the allergy is true

Question 4

How to document FHx

Answer 4

Immediate relatives
*AGE (alive or deceased) +overall health

Question 5

What does BALD CHASM stand for? (FHx)

Answer 5

B: blood pressure
A: Anemia
L: Lung
D: Diabetes
C: Cancer
H: Heart Disease
A: Addiction
S: Stroke
M: Mental health
*Any known genetic diseases

Question 6

What does social history show/

Answer 6

1. Personality
2. Lifestyle
3. Interests
4. Stresses, coping, support
5. Risk factors

Question 7

How can the patients lifestyle affect their health?

Answer 7

1. Can contribute to the etiology of illness
2. Aggravate or limit the severity of illness
3. Interfere or help with getting/ being well

Question 8

What does SAD ONE stand for? (SHx)

Answer 8

S: Smoking/tobacco/vaping
A: Alcohol
D: Drug use
O: Occupation
N: nutrition
E: Exercise

Question 9

What other info can be added to the SHx?

Answer 9

1. Spiritual assessment
2. Advance directive
3. Feel safe?
4. Education
5. Relationships
6. Hobbies

Question 10

What is the screening test for alcoholism?

Answer 10

CAGE
C: cut down
A: Annoyed
G: guilt
E: eye opener

Question 11

What is the screening test for IPV?

Answer 11

SAFE questions
S: stress/safety
A: afraid/abuse
F: friends/ family
E: emergency plan