Term
Start the Interview & CC
-Start the Interview |
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Definition
wash hands
shake hands
sit
eye level
good eye contact
good body language |
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Term
Start the interview & CC
-Establishes relationship |
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Definition
| address by name & formal title, focus on patient, obtain personal information, use understandable language, invite the patient’s story |
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Term
Start the interview & CC
-Gathered Information |
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Definition
| questions (open, closed, direct), techniques(facilitation, reflection, confrontation, interpretation, summarization, empathic responses) |
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Term
Start the interview & CC
-Elicit patient's perspective |
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Definition
| thoughts about nature, cause, feelings, expectations, effects on life, Hx similar experiences, response or efforts related to problem |
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Term
Start the interview & CC
-Establishes cheif complaint (CC) |
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Definition
| reason for visit, in patient’s words, in quotation marks |
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Term
History of Present Illness (HPI)
-Onset |
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Definition
| when did SX start, how long SX present (duration)? |
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Term
History of Present Illness (HPI)
-Palliative- (What makes it better?) |
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Definition
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Term
History of Present Illness (HPI)
-Provocative- (What makes it worse?) |
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Definition
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Term
History of Present Illness (HPI)
-Quality - of Sx |
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Definition
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Term
History of Present Illness (HPI)
-Radiation |
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Definition
| do symptoms affect other parts of the body? |
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Term
History of Present Illness (HPI)
-Severity - x/10 (With 10 being worst you have experiened) |
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Definition
| does CC affect activities, positions, work, psychological or physical well being? |
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Term
History of Present Illness (HPI)
-Timing |
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Definition
| SX associated with medications, activities, foods? |
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Term
Past medical History (PMH)
-Determines meds pt takes |
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Definition
| Prescriptions, Over-the-counter (OTC), to include supplements/herbals. List name, strength, dosage, how long & for what purpose (indication) |
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Term
PMH
-Elicits childhood illnesses/injuries |
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Definition
| Mumps, rubeola-rubella(measles), varicella (chicken pox), pertussis (whooping cough), polio, rheumatic fever, scarlet fever, other, major injuries, complications & residuals. |
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Term
PMH
-Adult chronic illness |
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Definition
| Diabetes, HTN, Cardiovascular dx, pulmonary dx, HIV cancer, & significant injuries. (Date, provider, tx, complications & residuals) |
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Term
PMH
-Past hospitalizations or surgery |
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Definition
| hospitalizations, surgeries,-diagnosis, date, hospital, treatment, procedure, complications, transfusions. |
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Term
PMH
-Inquiries about health maintenence |
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Definition
| Routine PE, Immunizations Adult: tetanus, influenza, pneumococcal, Hep B, Herpes Zoster, (if Pediatric: MMR, Polio, DPT, HIB, Hep B, HPV, Varicella), Screening tests--Pap smear, mammography, colonoscopy, digital rectal exam, Lipids, Hemoccult, PSA, Preventative care --Diet, exercise, sleep, safe sex, seat belts, sun screen, helmet use |
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Term
PMH (Family history)
-Elicits 3 generations |
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Definition
| (Grandparents, parents, siblings&/or children),-Age, health, Hx cancer, HIV, DM, HTN, cardiovascular, pulmonary, cause of death |
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Term
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Definition
| Occupation(s) and schooling level |
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Term
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Definition
| Housing/living conditions, utilities, home situation, married, children, significant other |
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Term
PMH (Social History)
-Sources of stress |
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Definition
| money, work, family, friends, health, habits, faith, time |
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Term
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Definition
| Caffeine, alcohol, tobacco or illicit drug use |
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Term
PMH (Social History)
-Important life experiences |
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Definition
| divorce, widowed, job history, military service, financial situation, retirement |
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Term
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Definition
| Leisure activities and activities of daily living (ADLs) (including personal and household) |
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Term
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Definition
| Religious beliefs or affiliations |
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