class made Midterm 2021-2022
Clinical Documentation Ch 1
Midterm Exam
Developing Relationship w/ Patient
• Patient-centered approach questions Box 1.1 pg 2
Effective communication
• Courtesy, comfort, connection & confirmation Box 1.2 pg 3
• Seek communication-greet pt, begin with open-ended questions, resist
interruptions, clear goals, eye contact, seated close to pt, ask parent or
other
individual to step out of room for confidential information
• Enhance pt response-open ended questions (tell me about…), direct question
(how long ago..). Avoid leading question (that wasn’t difficult to do, was it?)
o Facilitate, reflect, empathize, confront disturbing behavior, interpret
what you heard
• Barriers to communication-
o curiosity about you- sends message that you are real person and offers
trust
o anxiety- avoid overload of info, pace conversation, and present calmly
o silence- do not force conversation, ask open ended questions
o depression- screen for depression
o crying and compassion- offer tissue and say “it seems like you’re
feeling sad. It’s OK to cry”
o intimacy- respect modesty, but do not skip genital exam d/t modesty
o seduction- no tolerance for exploitation
o anger- Ok to say “it seems your angry. Tell me why”
o avoiding full story- come back to question “I think you may be more
concerned than you are saying”
o finances- discuss financial drain and provide resources
Patient Hx
Setting for interview
• face to face with patient w/out bulky items or computers between
Structure of interview
• identifiers (name, DOB, date, time, age, gender, race, SOI, referral source),
CC, HPI, PMH, FH, SH, ROS
Building Hx
o introduce self to pt
o do not address pt by first name when you do not expect it in return
o learn each person’s name in room
,class made Midterm 2021-2022
o do not be distracted by the electronic device
o Seek certainty from the pt “what concerns you most?”
o Conclude interview with review
▪ Ask pt to satisfy gaps, ask for questions, summarize what you’ve
heard, repeat instructions, explain next steps
• Sensitive issues
o Privacy, be direct and firm, do not apologize for question, do not preach,
use understandable language, do not push
o Take notes sparingly, if you must
o Alcohol-CAGE Box 1.3 p 8 to screen for alcoholism
▪ Cutting down, annoyance by criticism, guilty feeling, eye openers
▪ TACE and CRAFFT Questionnaires also available p 9
o Intimate partner violence- screen all females
▪ partner violence screen 1. Have you been hit, kicked, punched, or
hurt by someone in the last year? 2. Do you feel safe in your
relationship? 3. Is there a partner from a previous relationship who
is making you feel unsafe now?
▪ “the bruises you have, how did you get them?”
▪ If positive answers, mandate intervention such as social work or
mental health provider
▪ HITS box 1.6 p 10 screening for domestic violence
▪ Men should also be screened, but not mandated. His statements or
suspicious injuries will trigger interaction
o Spirituality
▪ FICA (Faith, Importance/Influence, Community, Address/Action in
Care)
• Sexuality and Gender Identity
o Ensure confidentiality
o Identity
▪ Gender neutral questions
• Tell me your living situation, are you sexually active,
in what way?
▪ NOT GENDER NEUTRAL
• Are you married, do you have a boyfriend/girlfriend?
• Outline of Hx
o Chief concern- why are you here?
▪ Infant/children- fears of adult and children
o HPI- health before onset of symptoms, description of symptoms,
symptoms analysis (location, duration, intensity, description/character,
aggravating/alleviating factors), description of attach, exposure to
infection/toxins, impact of illness on lifestyle (sexual, ADL’s, stress),
medications, alternative therapies, review of chronological events
▪ Infant/children- reaction of parent and child should be noted
▪ Pregnancy- description of pregnancy and previous medical care,
specific problems (bleeding, n/v, fatigue, edema)
,class made Midterm 2021-2022
o PMH-general health, gender, childhood illnesses, chronic disease,
immunization, surgery, serious injuries/disabilities, limitations,
medications, allergies, transfusions, recent screen, emotional
status
▪ Infant/children- note health and strength, health during
pregnancy, duration, place of birth, labor, delivery, infant
condition, apgar,
birth weight, feeding, development (see pg 16)
▪ Pregnancy- obstetric hx, menstrual hx, gynecologic hx, and include
risk for HIV, hepatitis, tb, environmental exposures,
o Family Hx- immediate blood relative hx
▪ Infant/children- gestational hx, health during pregnancy
▪ Pregnancy- genetic condition, multiple births, gestation diabetes,
preeclampsia, congenital anomalies
o Social hx- personal status (marital status, employment, hobbies, sources
of stress), habits, self0care, sexual hx, living conditions, military record,
religious preferences, access to care, social needs (insurance, housing
instability)
▪ Sexual Hx-5 P’s- partners, practices, protection from STI’s, Past
hx of STI’s, prevention of pregnancy
▪ Infant/children- school adjustment, masturbation, nail biting,
thumb sucking, bed wetting, rituals, reactions to prior illness,
injuries, or hospitalization
▪ Pregnancy- children, pets (toxoplasmosis), planned pregnancy,
adoption or abortion , gender preference, social/spiritual resources,
plans for labor/breast feeding, hx of abuse
o ROS- negative ROS is as important as positive ROS
▪ General- pain, fever, chills, malaise, fatigue, night sweats,
sleep patterns, weight change
• Infant/children- skin eczema, seborrhea, “cradle cap”
▪ Head/neck: head aches, dizzy, syncope, head injuries
• Eyes- vision changes, pain, glaucoma, eye drop use, trauma
hx
• Ears- hearing changes, pain, discharge, vertigo, infection
o Infant/children- otitis media
• Nose- sense of smell, colds, obstruction, epistaxis,
discharge, pain
o Infant/children- snoring, mouth breathing,
allergic rx
• Throat/mouth- change in voice, sore throats, bleeding, tooth
abscess, ulcers, change in taste, dental care
o Infant/children- dental care
▪ Lymph node- enlargement, tenderness, suppuration
▪ Chest/lungs- pain, dyspnea, cyanosis, wheezing, cough, sputum,
hemoptysis, night sweats, exposure to tb
▪ Breasts- pain, tenderness, d/c, lumps, mammogram results
, class made Midterm 2021-2022
▪ Heart/blood vessels- pain (precipitation, timing, duration, relieving
factors) palpitations, dyspnea, orthopnea, edema, HTN, previous
MI, exercise tolerance, EKG results
▪ Peripheral- claudication, cruising, thrombosis, thrombophlebitis,
▪ Hemotology- anemia, bruising
▪ GI- appetite, digestion, food intolerance, dysphagia, heartburn
n/v/d, bowel regularity, flatulence, hemorrhoids, hx of ulcer,
gallstones, polyps, tumor, diagnostic imaging,
▪ Diet- apetite, restriction, allergies, vitamins, caffeine use
▪ Endocrine- thyroid enlargement, heat/cold intolerance, weight
changes, DM, polydipsia, polyphagia, body hair, increase in
glove
size
▪ GU-dysuria, flank pain, urgency, frequency, nocturia,
hematuria, polyuria, discolored urine, hesitancy, dribbling,
stones, edema, incontinence, hernia, STI’s
• Infant/children- bed wetting
▪ MS- stiffness, pain, restriction of motion, swelling, redness,
heat, derformity
▪ Psych- depression, mood changes, concentration,
anxiety, agitation, tension, suicidal ideas, sleep
disturbances
▪ Menses- age of onset, regularity, duration, dysmenorrhea,
LMP, d/c/bleeding, itching, hx pap smear, hpv testing,
menopause, libido, intercourse pain, infertility
▪ Pregnancies- number, living, births, miscarriages,
abortion, duration of pregnancy, type of deliveries,
complications, contraceptives
▪ Male- puberty onset, erectile difficulties, emissions, pain, libido,
or infertility
o To conclude “is there anything else you want me to know?”
• Infants and children
o Dependable reporter at age 7
• Adolescents
o Ask open ended questions
o Risky behaviors- peer pressure, loosening attachment, poor school
performance, nonparticipation, poor self esteem need to act older,
susceptibility to advertising, internet, or social media
o Box 1.12 pg 18 adolescent concerns
o Screening tools
▪ HEEADSS (home environment, education/employment, eating,
activities, drugs, sexuality, suicide, safety)
▪ PACES (parents/peers, accidents/alcohol/drugs,
cigarettes, emotional issues, school/sexuality)
▪ CRAFFT (car, relax, alone, forget, friend, trouble)
• Pregnancy
o Post partum- depression
• Older adults
Clinical Documentation Ch 1
Midterm Exam
Developing Relationship w/ Patient
• Patient-centered approach questions Box 1.1 pg 2
Effective communication
• Courtesy, comfort, connection & confirmation Box 1.2 pg 3
• Seek communication-greet pt, begin with open-ended questions, resist
interruptions, clear goals, eye contact, seated close to pt, ask parent or
other
individual to step out of room for confidential information
• Enhance pt response-open ended questions (tell me about…), direct question
(how long ago..). Avoid leading question (that wasn’t difficult to do, was it?)
o Facilitate, reflect, empathize, confront disturbing behavior, interpret
what you heard
• Barriers to communication-
o curiosity about you- sends message that you are real person and offers
trust
o anxiety- avoid overload of info, pace conversation, and present calmly
o silence- do not force conversation, ask open ended questions
o depression- screen for depression
o crying and compassion- offer tissue and say “it seems like you’re
feeling sad. It’s OK to cry”
o intimacy- respect modesty, but do not skip genital exam d/t modesty
o seduction- no tolerance for exploitation
o anger- Ok to say “it seems your angry. Tell me why”
o avoiding full story- come back to question “I think you may be more
concerned than you are saying”
o finances- discuss financial drain and provide resources
Patient Hx
Setting for interview
• face to face with patient w/out bulky items or computers between
Structure of interview
• identifiers (name, DOB, date, time, age, gender, race, SOI, referral source),
CC, HPI, PMH, FH, SH, ROS
Building Hx
o introduce self to pt
o do not address pt by first name when you do not expect it in return
o learn each person’s name in room
,class made Midterm 2021-2022
o do not be distracted by the electronic device
o Seek certainty from the pt “what concerns you most?”
o Conclude interview with review
▪ Ask pt to satisfy gaps, ask for questions, summarize what you’ve
heard, repeat instructions, explain next steps
• Sensitive issues
o Privacy, be direct and firm, do not apologize for question, do not preach,
use understandable language, do not push
o Take notes sparingly, if you must
o Alcohol-CAGE Box 1.3 p 8 to screen for alcoholism
▪ Cutting down, annoyance by criticism, guilty feeling, eye openers
▪ TACE and CRAFFT Questionnaires also available p 9
o Intimate partner violence- screen all females
▪ partner violence screen 1. Have you been hit, kicked, punched, or
hurt by someone in the last year? 2. Do you feel safe in your
relationship? 3. Is there a partner from a previous relationship who
is making you feel unsafe now?
▪ “the bruises you have, how did you get them?”
▪ If positive answers, mandate intervention such as social work or
mental health provider
▪ HITS box 1.6 p 10 screening for domestic violence
▪ Men should also be screened, but not mandated. His statements or
suspicious injuries will trigger interaction
o Spirituality
▪ FICA (Faith, Importance/Influence, Community, Address/Action in
Care)
• Sexuality and Gender Identity
o Ensure confidentiality
o Identity
▪ Gender neutral questions
• Tell me your living situation, are you sexually active,
in what way?
▪ NOT GENDER NEUTRAL
• Are you married, do you have a boyfriend/girlfriend?
• Outline of Hx
o Chief concern- why are you here?
▪ Infant/children- fears of adult and children
o HPI- health before onset of symptoms, description of symptoms,
symptoms analysis (location, duration, intensity, description/character,
aggravating/alleviating factors), description of attach, exposure to
infection/toxins, impact of illness on lifestyle (sexual, ADL’s, stress),
medications, alternative therapies, review of chronological events
▪ Infant/children- reaction of parent and child should be noted
▪ Pregnancy- description of pregnancy and previous medical care,
specific problems (bleeding, n/v, fatigue, edema)
,class made Midterm 2021-2022
o PMH-general health, gender, childhood illnesses, chronic disease,
immunization, surgery, serious injuries/disabilities, limitations,
medications, allergies, transfusions, recent screen, emotional
status
▪ Infant/children- note health and strength, health during
pregnancy, duration, place of birth, labor, delivery, infant
condition, apgar,
birth weight, feeding, development (see pg 16)
▪ Pregnancy- obstetric hx, menstrual hx, gynecologic hx, and include
risk for HIV, hepatitis, tb, environmental exposures,
o Family Hx- immediate blood relative hx
▪ Infant/children- gestational hx, health during pregnancy
▪ Pregnancy- genetic condition, multiple births, gestation diabetes,
preeclampsia, congenital anomalies
o Social hx- personal status (marital status, employment, hobbies, sources
of stress), habits, self0care, sexual hx, living conditions, military record,
religious preferences, access to care, social needs (insurance, housing
instability)
▪ Sexual Hx-5 P’s- partners, practices, protection from STI’s, Past
hx of STI’s, prevention of pregnancy
▪ Infant/children- school adjustment, masturbation, nail biting,
thumb sucking, bed wetting, rituals, reactions to prior illness,
injuries, or hospitalization
▪ Pregnancy- children, pets (toxoplasmosis), planned pregnancy,
adoption or abortion , gender preference, social/spiritual resources,
plans for labor/breast feeding, hx of abuse
o ROS- negative ROS is as important as positive ROS
▪ General- pain, fever, chills, malaise, fatigue, night sweats,
sleep patterns, weight change
• Infant/children- skin eczema, seborrhea, “cradle cap”
▪ Head/neck: head aches, dizzy, syncope, head injuries
• Eyes- vision changes, pain, glaucoma, eye drop use, trauma
hx
• Ears- hearing changes, pain, discharge, vertigo, infection
o Infant/children- otitis media
• Nose- sense of smell, colds, obstruction, epistaxis,
discharge, pain
o Infant/children- snoring, mouth breathing,
allergic rx
• Throat/mouth- change in voice, sore throats, bleeding, tooth
abscess, ulcers, change in taste, dental care
o Infant/children- dental care
▪ Lymph node- enlargement, tenderness, suppuration
▪ Chest/lungs- pain, dyspnea, cyanosis, wheezing, cough, sputum,
hemoptysis, night sweats, exposure to tb
▪ Breasts- pain, tenderness, d/c, lumps, mammogram results
, class made Midterm 2021-2022
▪ Heart/blood vessels- pain (precipitation, timing, duration, relieving
factors) palpitations, dyspnea, orthopnea, edema, HTN, previous
MI, exercise tolerance, EKG results
▪ Peripheral- claudication, cruising, thrombosis, thrombophlebitis,
▪ Hemotology- anemia, bruising
▪ GI- appetite, digestion, food intolerance, dysphagia, heartburn
n/v/d, bowel regularity, flatulence, hemorrhoids, hx of ulcer,
gallstones, polyps, tumor, diagnostic imaging,
▪ Diet- apetite, restriction, allergies, vitamins, caffeine use
▪ Endocrine- thyroid enlargement, heat/cold intolerance, weight
changes, DM, polydipsia, polyphagia, body hair, increase in
glove
size
▪ GU-dysuria, flank pain, urgency, frequency, nocturia,
hematuria, polyuria, discolored urine, hesitancy, dribbling,
stones, edema, incontinence, hernia, STI’s
• Infant/children- bed wetting
▪ MS- stiffness, pain, restriction of motion, swelling, redness,
heat, derformity
▪ Psych- depression, mood changes, concentration,
anxiety, agitation, tension, suicidal ideas, sleep
disturbances
▪ Menses- age of onset, regularity, duration, dysmenorrhea,
LMP, d/c/bleeding, itching, hx pap smear, hpv testing,
menopause, libido, intercourse pain, infertility
▪ Pregnancies- number, living, births, miscarriages,
abortion, duration of pregnancy, type of deliveries,
complications, contraceptives
▪ Male- puberty onset, erectile difficulties, emissions, pain, libido,
or infertility
o To conclude “is there anything else you want me to know?”
• Infants and children
o Dependable reporter at age 7
• Adolescents
o Ask open ended questions
o Risky behaviors- peer pressure, loosening attachment, poor school
performance, nonparticipation, poor self esteem need to act older,
susceptibility to advertising, internet, or social media
o Box 1.12 pg 18 adolescent concerns
o Screening tools
▪ HEEADSS (home environment, education/employment, eating,
activities, drugs, sexuality, suicide, safety)
▪ PACES (parents/peers, accidents/alcohol/drugs,
cigarettes, emotional issues, school/sexuality)
▪ CRAFFT (car, relax, alone, forget, friend, trouble)
• Pregnancy
o Post partum- depression
• Older adults
