Advanced Health Assessment Midterm Study Guide
S O A P note - a method of documentation employed by health care providers
to write out notes in a patient's chart
Subjective, Objective, Assessment and Plan
A B C D skin lesion assessment - Asymmetry
Border irregularity
Color isn't uniform
Diameter >6cm (pencil eraser)
Evolving size, shape and color
Preferred qualities of a first impression - honesty, candor, openness,
flexibility, eager, explanatory, open to questions
patient centered care - providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient
values guide all clinical decisions
4 C's of effective communication - courtesy
comfort
connection
confirmation
Open ended questions goal - patient's description of answer
direct question goal - seeking specific information
Leading question goal - Limiting information to one focus / subject
,Advanced Health Assessment Midterm Study Guide
Reasons patients avoid the full story of the illness - dementia, alcoholism,
illness, sexual uncertainties, domestic violence, child abuse
Potential Barriers to Communication - - Curiosity about you
- Anxiety
- Silence
- Depression
- Crying and Compassionate Moments
- Seduction
- Anger
- Financial Considerations
2 goals of a patient history - 1. identify what the patient's problem is
2. establish reliability of the patient
Why is it important to complete a review of systems after a history? - to
identify complementary or symptoms that may seem unrelated
Tips when discussing a sensitive topic - provide privacy, direct & firm, no
apologies, no judgement, avoid confrontation, no jargon, document carefully
4 steps in approaching the examination of sensitive areas - 1. introduction &
why
2. open ended questions to explore pt's feelings
3. repeat what's been said & give feedback
4. take questions from pt
, Advanced Health Assessment Midterm Study Guide
TACE questions - Does it *T*ake more than two drinks to get you drunk?
Have people *A*nnoyed you by criticizing your drinking?
Have you ever felt you ought to *C*ut down on your drinking?
Have you ever had a drink first thing in the morning to steady your nerves
(*E*ye opener)?
Partner Violence Screen - Have you been hit, kicked, punched or otherwise
hurt by someone within the past year?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is making you feel unsafe
now?
HITS tool - Hurt
Insult
Threaten
Scream
*for intimate partner violence
FICA tool for spiritual assessment - Faith, belief, meaning
Importance & influence
Community
Action in care
Sexuality History Goal - identify risk factors for unintentional pregnancy or
STIs
S O A P note - a method of documentation employed by health care providers
to write out notes in a patient's chart
Subjective, Objective, Assessment and Plan
A B C D skin lesion assessment - Asymmetry
Border irregularity
Color isn't uniform
Diameter >6cm (pencil eraser)
Evolving size, shape and color
Preferred qualities of a first impression - honesty, candor, openness,
flexibility, eager, explanatory, open to questions
patient centered care - providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient
values guide all clinical decisions
4 C's of effective communication - courtesy
comfort
connection
confirmation
Open ended questions goal - patient's description of answer
direct question goal - seeking specific information
Leading question goal - Limiting information to one focus / subject
,Advanced Health Assessment Midterm Study Guide
Reasons patients avoid the full story of the illness - dementia, alcoholism,
illness, sexual uncertainties, domestic violence, child abuse
Potential Barriers to Communication - - Curiosity about you
- Anxiety
- Silence
- Depression
- Crying and Compassionate Moments
- Seduction
- Anger
- Financial Considerations
2 goals of a patient history - 1. identify what the patient's problem is
2. establish reliability of the patient
Why is it important to complete a review of systems after a history? - to
identify complementary or symptoms that may seem unrelated
Tips when discussing a sensitive topic - provide privacy, direct & firm, no
apologies, no judgement, avoid confrontation, no jargon, document carefully
4 steps in approaching the examination of sensitive areas - 1. introduction &
why
2. open ended questions to explore pt's feelings
3. repeat what's been said & give feedback
4. take questions from pt
, Advanced Health Assessment Midterm Study Guide
TACE questions - Does it *T*ake more than two drinks to get you drunk?
Have people *A*nnoyed you by criticizing your drinking?
Have you ever felt you ought to *C*ut down on your drinking?
Have you ever had a drink first thing in the morning to steady your nerves
(*E*ye opener)?
Partner Violence Screen - Have you been hit, kicked, punched or otherwise
hurt by someone within the past year?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is making you feel unsafe
now?
HITS tool - Hurt
Insult
Threaten
Scream
*for intimate partner violence
FICA tool for spiritual assessment - Faith, belief, meaning
Importance & influence
Community
Action in care
Sexuality History Goal - identify risk factors for unintentional pregnancy or
STIs
