Week 1 - Taking a hx lecture & Week 2 - Clinical Documentation lecture

Question 1

WWE, general physical, sports physical, and well-child check up are all examples of what type of exam? This would be a head-to-toe, along w/a full hx.

Answer 1

Comprehensive

Question 2

A ___ ___ exam would be a physical plus a problem. An example would be a physical plus a sore throat.

Answer 2

comprehensive plus

Question 3

A ___ exam would be for a specific problem. An example would be fever, or sinus drainage.

Answer 3

focused

Question 4

___ data is what the pt says. ___ data is what is physically seen.

Answer 4

Subjective, objective

Question 5

OLDCART stands for:

Answer 5

onset, location, duration, characteristics, aggravating factors, relieving factors, Timing

Question 6

The ___ ___ is why the pt is there to see you and in their own words.

Answer 6

chief complaint

Question 7

HPI stands for ___ ___ ___ ___ and includes assessing for ___.

Answer 7

history of present illness, OLDCART

Question 8

In a ___ exam, only put what relates to the current complaint and what the pt is there for in the note.

Answer 8

focused

Question 9

PMH stands for ___ ___ ___ and includes general health, current medical problems, childhood illnesses, adult/chronic illnesses, immunizations, hospitalizations, sgy, injuries, sexual health, hematologic, health screenings, and any recent labs/diagnostics.

Answer 9

past medical hx

Question 10

The medication list should include all ___, ___, ___, or ___.

Answer 10

Rx’s, OTC’s, herbs, vitamins

Question 11

GTPAL stands for:

Answer 11

gravida (# of preg), term, preterm, abortions (spontaneous), living

Question 12

Family hx should include:

Answer 12

mother, father, siblings, MGM, MGF, PGM, PGF, and any other family member w/chronic disorders

Question 13

___/___ hx includes marital status/living arrangement, occupation, education, diet, exercise, religious/cultural practices, sleep, tobacco/alcohol/drug use, caffeine, stress, safety, domestic abuse, sexual health, recent travel, concerns w/cost.

Answer 13

Personal/social

Question 14

ROS is a review of any ___ problems going on now.

Answer 14

current

Question 15

Items in the ___ must match items in ___ ___ ___. For example, Rx for lisinopril, blood work, and follow up all relate to uncontrolled HTN.

Answer 15

assessment, plan of care

Question 16

The 4 steps to a diagnostic process include:

Answer 16

take a hx, perform a physical exam, decide the dx, make a plan

Question 17

When performing the health hx interview, use ___-___ questions, and ask permission before ___.

Answer 17

open-ended, touching

Question 18

Special populations include:

Answer 18

children, adolescents, pregnant women, geriatrics, pt’s w/disabilities/impairments

Question 19

The CAGE questionnaire stands for:

Answer 19

C - Have you ever felt like you should CUT down on your drinking?
A - Are people ANNOYED by your drinking?
G - Have you ever felt GUILTY about your drinking?
E - Have you ever had a drink in the morning (EYE-opener) to steady your nerves or to get rid of hangover?

Question 20

___ ___ ___ includes: general, neuro, HEENT, pulmonary, cardiac, (breasts if female), GI, GU, musculoskeletal, neuro, peripheral vascular, dermatologic, hematologic, psych

Answer 20

Review of systems

Question 21

A complete/comprehensive exam is a full ___-___-___, whereas the focused exam only looks at ___ information.

Answer 21

head-to-toe, pertinent