Week 1 - Taking a hx lecture & Week 2 - Clinical Documentation lecture Flashcards
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.
Comprehensive
A ___ ___ exam would be a physical plus a problem. An example would be a physical plus a sore throat.
comprehensive plus
A ___ exam would be for a specific problem. An example would be fever, or sinus drainage.
focused
___ data is what the pt says. ___ data is what is physically seen.
Subjective, objective
OLDCART stands for:
onset, location, duration, characteristics, aggravating factors, relieving factors, Timing
The ___ ___ is why the pt is there to see you and in their own words.
chief complaint
HPI stands for ___ ___ ___ ___ and includes assessing for ___.
history of present illness, OLDCART
In a ___ exam, only put what relates to the current complaint and what the pt is there for in the note.
focused
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.
past medical hx
The medication list should include all ___, ___, ___, or ___.
Rx’s, OTC’s, herbs, vitamins
GTPAL stands for:
gravida (# of preg), term, preterm, abortions (spontaneous), living
Family hx should include:
mother, father, siblings, MGM, MGF, PGM, PGF, and any other family member w/chronic disorders
___/___ 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.
Personal/social
ROS is a review of any ___ problems going on now.
current
Items in the ___ must match items in ___ ___ ___. For example, Rx for lisinopril, blood work, and follow up all relate to uncontrolled HTN.
assessment, plan of care
The 4 steps to a diagnostic process include:
take a hx, perform a physical exam, decide the dx, make a plan
When performing the health hx interview, use ___-___ questions, and ask permission before ___.
open-ended, touching
Special populations include:
children, adolescents, pregnant women, geriatrics, pt’s w/disabilities/impairments
The CAGE questionnaire stands for:
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?
___ ___ ___ includes: general, neuro, HEENT, pulmonary, cardiac, (breasts if female), GI, GU, musculoskeletal, neuro, peripheral vascular, dermatologic, hematologic, psych
Review of systems
A complete/comprehensive exam is a full ___-___-___, whereas the focused exam only looks at ___ information.
head-to-toe, pertinent
