Term
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Definition
| Clinical assessment process |
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Term
| What are the 11 steps of a CAP? |
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Definition
1+2) Gather information
3) Identify the problem
4) Identify Exclusions for self-treatment
5) Identify alternative solutions
6) Select and optimal solution
7-8) Prepare and implement a plan
9-11) Educate Patient |
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Term
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Definition
Qu: Quickly and accurately assess the patient
E: Establish that the patient is an appropriate self-care candidate.
S: Suggest appropriate self-care strategies.
T: Talk with the patient |
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Term
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Definition
P: Precipitating events
P: Palliative factors
Q: Quality
R: Radiation
S: Site
S: Severity
T: Temporal Factors
A: Associated Symptoms |
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Term
| What would you ask the patient for each PQRSTA? |
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Definition
P: What happened that lead you to feeling this way?
P: Have you tried anything to help with the symptoms?
Q: Describe the exact symptoms.
R: How are the symptoms progressing? (Head to shoulders, neck to back, etc.) What order did the symptoms occur?
S: Where are the effected areas?
S: On a scale of 1-10, how much does it hurt/itch/burn/etc?
T: How long have these symptoms lasted? Intermittent? Consistent?
A: Anything else I should know about? |
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Term
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Definition
| Medication Related Problem |
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Term
| What are all the possible MRPs? (9) |
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Definition
(1) Indication without treatment
(2) Treatment without indication
(3) Underdose
(4) Overdose
(5) Wrong treatment
(6) Drug interaction
(7) Adverse side effect
(8) Failure to receive treatment
(9) Inappropriate monitoring |
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Term
| What does SOAP note mean? |
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Definition
S: Subjective
O: Objective
A: Assessment
P: Plan |
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Term
| What does subjective mean? |
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Definition
Cannot be measured.
Information from patient.
Open for interpretation.
May not be accurate or reproducible. |
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Term
| What does CC stand for and what does it mean? |
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Definition
| Chief Complaint: Reason for seeking medical attention |
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Term
| What does HPI stand for and what does it mean? |
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Definition
| History of Present Illness: Things that lead to CC, severity, duration, physical findings, and labs relating to CC |
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Term
| What does PMH stand for and what does it mean? |
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Definition
| Past Medical History: Disease states hospitalization history, surgeries |
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Term
| What does SH stand for and what does it mean? |
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Definition
Social history: Recreational drug, alcohol, tobacco, caffeine use.
Marital status.
Occupation.
Education.
Pets.
Travel.
Environmental Exposures. |
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Term
| What does FH stand for and what does it mean? |
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Definition
| Family HIstory: History of disease in family, cause of deaths, etc. |
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Term
| Is Medication history subjective or objective? |
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Definition
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Term
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Definition
Can be measured.
Weight, height, BMI, Blood pressure, etc.
Not influenced by emotions.
Labs and Diagnostic tests. |
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Term
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Definition
Review of Symptoms and Physical Exam:
vitals and physical findings |
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Term
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Definition
Analysis of subjective and objective information.
Identify goals of therapy.
Document rationale for plan. |
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Term
| How should the plan be organized? |
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Definition
| It should be organized by disease state. |
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Term
| Is a follow-up always necessary? |
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Definition
| A follow-up must be planned. Therapeutic outcomes and negative outcomes potentially expected may be listed here. |
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