therapeutic communication/health history; privacy & confidentiality, and documentation

Question 1

What are the 3 types of health histories?

Answer 1

comprehensive, focused, and emergent

Question 2

What does OLDCARTSS stand for?

Answer 2

O: Onset – when did it start?
L: Location – where is it located?
D: Duration – how long have you had it?
C: Character – can you describe it?
A: Aggravating/alleviating factors – what makes it better/worse?
R: Radiation – does the pain radiate to any other location
T: Timing – when does it happen? Does it come and go?
S: Severity – how bad scale of 1-10?
S: Self-perception – Do you have an idea of what’s causing it?

Question 3

What are the 4 phases of interview process?

Answer 3

1. Pre-interactive phase – read chart, before client is present
2. Beginning phase – set’s tone, introduce yourself and role
3. Working phase – asking open and closed questions, gathering data
4. Closing phase – plan moving forward, next steps, questions

Question 4

What is OLDCARTSS used for/to examine?

Answer 4

Reason for seeking care/presenting illness

Question 5

What is the difference between privacy and confidentiality?

Answer 5

Privacy is about people; confidentiality is about duty to protect information