Summer 15 Flashcards
Factors that Contribute to Disparities in Health
Education, Insurance Status, Segregation, Immigration Status, Healthcare Provider Behavior
Health literacy
Language Barrier
4 Objectives of the Medical Interview
1) Gather information
2) Establish Rapport
3) Educate
4) Support and Motivate
How to introduce yourself as a PA
Physician assistant
Healthcare provider
Healthcare team with collaborative physician
Licensed and Certified
Symptoms
subjective, what patient describes with words.
Signs
Objective, physiologic and quantifiable observations
Complete Medical History
1) Chief complaint
2) HPI
3) Past medical history
4) Past surgical history
5) Family History
6) Social History
7) Review of Systems
Chief Complaint
Why is patient here TODAY?
Documentation: verbatim, in quotes
HPI
description of patient’s CC starting from last time patient felt well.
7 Dimensions of a Complaint
- Location (include radiation)
- Quality
- Severity (0-10)
- Timing (duration, frequency, consistency)
- Context (setting, onset)
- Modifying factors (palliation, provocation)
- Associated signs or symptoms
+ risk factors
L.O.C.A.T.E.S.
Location Other associated Sxs Character Alleviating/Aggravating Timing Environment Severity
+ Risk Factors
7 Ways to Facilitate Communication
- Facilitation - by posture, action or words. Encourage patient to say more.
- Reflection - repetition of patient’s own words
- Clarification - request clarification when a patient’s statements are unclear
- Empathetic Response
- Confrontation - point out contradictions
- Interpretation
- Summation
Components of Health History
- CC
- HPI
- PMH
- Past Surgical History
- Social History
- Medications
- Allergies
- Family History
- Review of Systems
Documenting Past medical history
- Current/active problems at the top of the list
- Include date of Dx and treating provider
- Include if problem is controlled or not
Past Surgical History
- List type of surg., date, and hospital/surgeon if known
- List any complications
- Most recent at top of list
- Include diagnostics
Documenting Medications
- List all meds, supplements, even OTC
- List dose, frequency, prescribing provider
- For PRN meds, how often do they take them?
- Is pt. adherent
Documenting Allergy and Sensitivity
- Include drugs, foods, environmental irritants
- List substance and type of RxN
- Most life threatening go at top of list
Documenting Health Maintenance
- Includes health screenings and preventative care.
- Name and date of screening, immunization, etc.
Documenting Family History
1st degree relatives: parents, siblings, children known family diseases family traits psychiatric illnesses * Note alive or deceased
Documenting Social History
- document in narrative style, not a list
- demographics, education, nutrition, hobbies, substances, sexual history
ROS
- inventory of specific body systems, a “catch all”
- Determines pertinent positives and negatives
- NO DIAGNOSES IN ROS
Documenting the ROS
List organ system, list positives first, then negatives
If you discover a + finding related to HPI, put it there!
If you discover a + finding not related to HPI, put it in PMH
