MA: Patient Assessment
|Def. Holistic care||The assessment of patient's health status with physical, cognitive, psychosocial , and behavioral data|
|What is the patients "self history" usefull for?|| 1. diagnosing patient|
2. treating the patient
3. allows the patient more participation in the process
|How can the "self history" form be completed|| 1. Mailed to the patient's home before the appointment|
2. completed in the office during the first visit.
|How should the Medical Information be collected?||1. The interview should be physically comfortable and conductive to confidential communications|
2. do not express surprise or displeasure at any of the patientstatements
3. record the information in an organized manner, exactly as given by the patient without opinion or interpretaion.
4. Include CC< vital signs, weight, height, pain scale
|What does the Medical history consist of?|| 1. Patient database|
-address, insurance, DOB
2. Past medical history (PMH)
- "have you ever had"
3. Family History (FH)
- "is your x healthy"
4. Social history (SH)
-smoke, drink, food
5. Review of systems (ROS)
- covers existing or potential health problems and physical findings
|What is the key to creating a caring therapeutic environment?||Empathy|
|What does empathy require those interested in healthcare services to do?|| examine their own values, beliefs, and actions. |
"here what they are saying, without judging them until all statistics/ test complete"
|What are two Therapeutic Techniques?|| 1. Active listening|
2. Nonverbal communication
|What is the active process involved in listening?|| 1. Restatement|
- repeat patients symptoms back to them
- stating an observation or recognitaion of patients feelings
- summarize patients thoughts
|Aprroximately what percent of patients interactions occur through nonverbal language?||90%|
|successful patient interaction has what points?||congruent verbal and nonverbal messages|
|How do you prepare the appropriate enviroment in a health setting?|| 1. ensure privacy|
2. refuse interruptions
3 prepare comfortable surroundings?
4. take judicious notes
|...||for specific information that can be anwsered with only a few words.|
|This is the contract between the medical assistant and patient?||Interviewing the patient|
|What are the three parts to interviewing the patient|| 1. initiation or introduction|
2. the body
3. the closing
|What are few interview barriers||...|
|When obtaining the Health History of a child, what should be done?|| 1. The environment should be safe and attractive.|
2. do not keep children and their caregivers waiting any longer than necessary.
3. Do not offer a choice unless the child can truly make one.
-when to take a shoot= not
4. Explain procedure in simple terms
injection not shot.
|What should be done during Child Examination?||...|
|...|| -The child may refuse to leave her mother's lap or may want to hold a favorite toy during the procedure. |
- Look for signs of anxiety such as thumb-sucking or rocking
|...|| less touching of the kid that is stuck to maother|
- do everything first then touch kid if necessary.
|How should one treat Adolescents.||...|
|How should you handle adult patients?|| 1. Patient educatin is extremely important|
2. Use lay language, and involve the patient in treatment
3. Stress-related health problems are frequently seen
4. Emphasize preventive healthcare measures.
5 Never use last name outloud but can in private
|Patients Body System Assessment|| 1. Apperance|
2. head and neck
3. E, N, E
4. Mouth and throat
10. Lymph glands
14. Arm, legs and feet.
|...|| Objective findings|
-somehting that can be measured, inspected, palpated, ausculated, or manipulated.
|...|| Subjective report form patient|
-patient complaints regarding how he or she feels,
-measure pain on a scale of 1 to 10
-cardinal symptoms: those most helpful in diagnose
|What kind of documenation and how obtained?||...|
|...||all pertinent signs and symptoms|
|What is the Basic Charditing Methods? and the other two?||...|
|What are the steps involved in POMR|| 1. Database|
2. Problem list
4. Progress notes : use SOAPE formate
|What Is the SOAPE Notes|| S- subjective data|
- C/C in patients words
O- objective data
- anything that is observed or measureable
- physicians tentative diagnosis
P - plane of care
-physician documents how health problem will be managed
-assessment of treatment outcome.
|When is the perfect time to initiate patient education?||During the initial patient interview|