This section of the Medical History that helps uncover existing or potential health problems
Past history
Which is likely to have to most influence on the accuracy and completeness of the information obtained from the patient during the medical history
The privacy of the area in which the interview takes place
Which medical record system has a standard format that makes it easy to read and audit?
Problem Oriented
During the Physical exam, the pt reports a continual ache in the right elbow. This info is call a
symptom
Which of the following includes insurance info
Database
Which of the following includes demographic info
database
Which of the following sections of the medial record includes the physical exam finding
ROS
Which of the following includes the pts dietary habits, smoking, alcohol
Social history
Which of the following involves asking a question or summarizing a pt thoughts
Clarification
Which is an open-ended question
what brings you to the office today?
Information that you gather from a pt interview is
Subjective
Which questions would encourage the pt. to continue to communicate
Tell me about how your arm feels righ now
Which explains a sign of disease
Elevated blood pressure
Which is the most important when conducting a patient interview
Providing uninterrupted privacy
Factors that affect patient learning
perception of the disease, age, emotional state, learning style.
All written material should be in large font or large print for which of the following pts.
Patient w/ vision loss.
Who benefits most if you stand in front of pt or withing the persons field of vision before beginning to speak
A patient with hearing loss.
HIPAA restrictions on PHI dictate
Releasing pt information only to those identified on the patient authorization form
When developing a pt education pamphlet on diabetes mellitus. What is important
Use language that is a 6 to 8 grad level
How have you been feeling? is what kind of question
Closed
Tell me about your back pain, is what kind of question
Open
Do you smoke? is what kind of question
Closed
When did the nausea start? is what kind of question
closed
Pain is what form of question
Subjective
Nausea is what form of question
Subjective
Dizziness is what form of question
Subjective
Labored respiration is what form of questions
objective
Color of the skin is what form of question
Objective
Back pain is what form of question
Subjective
Abdominal pain is what form of question
Subjective
before eating
ac
hs
hour of sleep
Rx
treatment
bid
twice a day
This legal document must be signed by the patient inorder to authorize a attorney to see their records
Power of attorney
