Vitals Flashcards
Yes or no: a patient’s idea of treatment success is being able to successfully manage the disease
Yes, the patient would like to know they were heard and that their situation will be managed appropriately
What is the most important part for the CMA to make feel during a physical exam?
We are to put the patient at ease. Patients come in sick and/or nervous and we are to make them comfortable
How should we help the patient understand that their appointment was for a single issue occuring, but wants to talk to the doctor about multiple problems instead?
Make sure the patient understands we have limited time in order to see all patients, but if time permits we will try
What part of the medical history includes notes and location, quality, and timing?
This is called history present illness
Is the review of systems the physician’s overall assessment of the major body functions? Yes or no
Yes, the review of systems is where a patient is fully assessed using all the body systems
Are a chronological set of notes for each visit a format for a source-oriented medical record? Yes or no
Yes
Is it important for the CMA during a medical exam to make sure and ask the patient whether they have any questions? Yes or no
Yes, make sure the patient feels they have been heard. Encourage them to ask any questions
What is the best way to communicate with an uncommunicative patient during a physical exam and review of their medical history?
Allow for the patient to see samples/examples to review in order to help get through the exam
How should a CMA ask a patient about sensitive topics such as alcohol and drug use?
These are uncomfortable topics for most people. Make sure to be non-judgemental. Establish a good rapport
What should the CMA do when asking necessary questions needed for the patient’s medical history intake, but the patient refuses to answer the questions regarding sexual history?
Make sure that if you skip that particular question, you come back around to asking again
Which body system is the CMA reviewing when assessing joint stiffness, muscle pain, and limitation of mobility?
The musculoskeletal system
Which body system is the CMA reviewing when assessing changes in a patient’s speech?
The neurological system
Which body system is the CMA reviewing when assessing SOB (shortness of breath)?
The respiratory system
Yes or no: patient-oriented format is NOT a common medical records format
Yes, it is not
What are the major components of the problem-oriented medical record?
You would expect to see database, problems list, diagnostics and treatment plan, and progress notes
What is the most appropriate action in order to make a correction when an error has been made in a patient’s chart?
When correcting errors, draw a single line through the text and place initials/date
What is the correct order for information placed chronologically in the chart?
Primary provider notes, EKG and X-rays, hospital notes, consultations, correspondence
When helping a physician prepare a room, you have to take the patient in to the room, confirm their identity, and put the patient at ease. What would be the next step in preparing the room for a physician and client assessment?
Explain the purpose and importance of the information needed
What is the most important thing to consider when asking the patient questions during a health history interview?
Patient understanding of information
What is considered the patient’s chief concern: disease, illness, treatment, or medications?
Illness
What is considered the physician’s chief concern: disease, illness, treatment, or medications?
Disease
What is included in patient demographic information?
Full name, address, and telephone number
Is insurance history involved within the patient’s medical history form? Yes or no
No
Does HIPPA involve description of various treatments for patients? Yes or no
Yes
