pt.assment chapter 4
close-ended questions beinfts ?
A. Used to assess key issues that may be important to the differential diagnosis B. Can be answered with a yes or no C. Psychologically, these are generally perceived as a notice that the convo will be coming to an end
Benfits of Summarize the information in the history are that it
Allows the patient to verify the accuracy of the pharmacists' comprehension of the answers they have provided
All patient histories begin with
Chief Complaint History
most commonly used form of medical history is
Chief Complaint History
Provider-Oriented History is
Designed to get specific types of information from the patient to use to make a diagnosis, with less attention paid to personal, social, and emotional aspects.
the 2nd step in obaning patient history is what ?
Follow with close-ended questions
the 2nd step in obaning patient history is what ?
Follow with more focused open-ended questions to obtain more specific information
Complete Medical History incudles
History of present illness (HPI) Past medical history problems in a problem list Family history Personal/social history
•patient Objective data inculde
Laboratory tests Medical imaging test results Physical examination
the diffent kins of [atient history are ?
Patient-Oriented History Provider-Oriented History Complete Medical History Chief Complaint History
SBAR stands for ?
Situation, Background, Assessment, and Recommendation
the 1st step in obaning patient history is what ?
Start with broad open-ended questions to begin the interview A. Require a more detailed answer in the patient's own words B. Preferred because their use provides more extensive information
the 4th step in obaning patient history is what ?
Summarize the information in the history
Silence is a
a powerful nonverbal encouragement technique.
• Reflecting or empathetic responses
are used to explore and acknowledge feelings; help the patient calm down and demonstrate a caring attitude by the interviewer.
Chief Complaint History is alskno known as
as the HPI —
The A in LOQQSAM stands for ?
associated symptoms looks for other symptoms that may help characterize the symptom patter to help identify the specific cause
• Verification of patient identity and the introduction are important
history to the beginning
PATIENT HISTORY
information needed to accurately assess a patient's symptom complex
Patient comfort
is important
One similar process used for nurse-physician communication in many hospitals
is the SBAR technique.
The L in LOQQSAM stands for ?
location questions attempt to find the anatomical location of the symptom and where it may move (radiation)
The M in LOQQSAM stands for ?
modifying factors questions are used to find out what makes the symptom better and what makes it worse ex "What have you tried to make it better?" "What seems to make it better?" "What makes it worse?
The O in LOQQSAM stands for ?
onset questions are used to assess date/time the symptom as possible
Patients will be more open and forthcoming in a ?
private environment.
The Q in LOQQSAM stands for ?
quality questions probe for a detailed description of as many aspects of the symptom as possible • Should be in the patient's own words if possible
The second Q in LOQQSAM stands for ?
quantity questions attempt to measure the severity and/or frequency of the problem • Severity: "How bad is it?" • Frequency: "How often does this happen?"
LOQQSAM pneumonic is used to what ?
remember the structure and content of chief complaint history taking
The S in LOQQSAM stands for ?
setting refers to the circumstances in which the symptom occurs
Patient-Oriented History explores
the patients' feelings regarding the physical aspects of the symptoms, personal or social components of the symptoms, and the patient's emotional reactions to the symptoms of disease.
PATIENT HISTORY Subjective data inculde
◦When the patient is telling their story