Health assessment midterm study guide2021-2022.
HEALTH ASSESSMENT MIDTERM
1-5 questions
Building A Complete Health History (Week 1) Chapters 1 & 26
•Communication techniques used to obtain a patient’s health history Chapter
1
- Open ended questions: gives the patient discretion about the
extent of the answer
- Direct question: seeks specific information
- Leading question: most risky, may limit information
- Courtesy, comfort, connection, confirmation
- CAGE questionnaire screening: designed to help diagnose alcoholism
- CRAFT screening: ETOH and substance abuse in adolescents (Car,
Relax, Forgot, Friends, Trouble)
- TACE screening: drinks does it take to feel high, people Annoyed
you about your drinking, Cut back drinking, Eye opener drink in the
AM
- Partner violence screen (PVS): hit kicked or punched, feel unsafe…
- Domestic Violence (HITS): Hurt you physical, Insult you, Threaten
you, Scream at you?
- Spirituality (FICA): Faith, Importance, Community, Address
- Types of histories: Complete, inventory (touches up on major
points), Problem (focused, acute life-threatening problem), Interim
(designed to chronicle events that have occurred since last meeting)
•Recording and documenting patient information Chapter 26
- Write out abbreviations Copy and paste or carry forward (CPCF)
- International Classification of Disease (ICD): diagnostic coding
system that classifies diseases and injuries and u used to track
mortality and morbidity
- Geriatric screening tool: Katz Index consists of six items (bathing,
dressing, toileting, transferring, continence and feeding
- Geriatric screening tool: Lawton Instrumental ADL-scale consists of
eight items in women (ability to use the telephone, shopping, cooking,
housekeeping, doing laundry, taking own medication, making
transports, and ability to handle finances)
Functional impairment was defined as dependency on at least one
domain of ADL (score <6) or IADL (a score <8 from women or <5 for
men). Functional decline was defined as deterioration on at least one
domain of ADL or IADL compared to baseline (decline ≥1 point).
- Sullivan Book:
CPTP is a listening of descriptive terms and identifying code for
reporting medical services and procedures
SOAP note documentation
- S: subjective (what patient tells you)
- O: objective (observations)
,Health assessment midterm study guide2021-2022.
- A: assessment (interpretation and conclusions)
- P: plan (diagnostic testing, rationale for decisions)
•Subjective vs objective information when documenting
,Health assessment midterm study guide2021-2022.
- S: pain (use pain score)
- O: relate findings to the process of inspection, palpation,
auscultation, percussion. “no masses on palpation” “tympanic
membranes are pearly gray”
- O: Use anatomic landmarks to add precision
- O: Findings that vary by degrees are customarily graded or
recorded in an incremental scale format (pulse amplitude, heart
murmur intensity, muscle strength, DTR
- Illustrations useful in describing the origin of pain and where it
radiates and the size, shape and location of a lesion
- HX of present illness: OLDCARTS: onset, location, duration,
character, aggravating factors, relieving factors, temporal factors,
severity of symptoms
•Ethical decision making and beneficence
- Beneficence: doing good
Diversity and Health Assessment – Bullets 6, 7,
8 Cultural Awareness and Diversity
Achieving cultural competence is a learning process that requires self-
awareness, reflective practice, and knowledge of core cultural issues
A culturally competent health care provider adapts to the unique
needs of patients of backgrounds and cultures that differ from his or
her own
Culture, in its broadest sense, reflects the whole of human behavior,
including ideas and attitudes; ways of relating to one another;
manners of speaking; and the material products of physical effort,
ingenuity, and imagination.
The stereotype, a fixed image of any group that denies the potential of
originality or individuality within the group
Multiple studies have shown that health care providers activate these
implicit stereotypes, or non-conscious bias, when communicating with
and providing care to minority patients
Members of racial and ethnic groups are not uniform. Each group is
highly heterogeneous and includes a diverse mix of immigrants,
refugees, and multigenerational Americans who have vastly different
histories, languages, spiritual practices, demographic patterns, and
cultures
Culturally competent care requires that health care providers be
sensitive to patients' heritage, sexual orientation, socioeconomic
situation, ethnicity, and cultural background
When cultural differences exist, be certain that you grasp exactly what
the patient means and know exactly what the patient thinks you mean
in words and actions The definition of “ill” or “sick” is based on the
individual's belief system and is determined in large part by his or her
enculturation.
, Health assessment midterm study guide2021-2022.
Socioeconomic, spiritual, and lifestyle factors affecting diverse populations
HEALTH ASSESSMENT MIDTERM
1-5 questions
Building A Complete Health History (Week 1) Chapters 1 & 26
•Communication techniques used to obtain a patient’s health history Chapter
1
- Open ended questions: gives the patient discretion about the
extent of the answer
- Direct question: seeks specific information
- Leading question: most risky, may limit information
- Courtesy, comfort, connection, confirmation
- CAGE questionnaire screening: designed to help diagnose alcoholism
- CRAFT screening: ETOH and substance abuse in adolescents (Car,
Relax, Forgot, Friends, Trouble)
- TACE screening: drinks does it take to feel high, people Annoyed
you about your drinking, Cut back drinking, Eye opener drink in the
AM
- Partner violence screen (PVS): hit kicked or punched, feel unsafe…
- Domestic Violence (HITS): Hurt you physical, Insult you, Threaten
you, Scream at you?
- Spirituality (FICA): Faith, Importance, Community, Address
- Types of histories: Complete, inventory (touches up on major
points), Problem (focused, acute life-threatening problem), Interim
(designed to chronicle events that have occurred since last meeting)
•Recording and documenting patient information Chapter 26
- Write out abbreviations Copy and paste or carry forward (CPCF)
- International Classification of Disease (ICD): diagnostic coding
system that classifies diseases and injuries and u used to track
mortality and morbidity
- Geriatric screening tool: Katz Index consists of six items (bathing,
dressing, toileting, transferring, continence and feeding
- Geriatric screening tool: Lawton Instrumental ADL-scale consists of
eight items in women (ability to use the telephone, shopping, cooking,
housekeeping, doing laundry, taking own medication, making
transports, and ability to handle finances)
Functional impairment was defined as dependency on at least one
domain of ADL (score <6) or IADL (a score <8 from women or <5 for
men). Functional decline was defined as deterioration on at least one
domain of ADL or IADL compared to baseline (decline ≥1 point).
- Sullivan Book:
CPTP is a listening of descriptive terms and identifying code for
reporting medical services and procedures
SOAP note documentation
- S: subjective (what patient tells you)
- O: objective (observations)
,Health assessment midterm study guide2021-2022.
- A: assessment (interpretation and conclusions)
- P: plan (diagnostic testing, rationale for decisions)
•Subjective vs objective information when documenting
,Health assessment midterm study guide2021-2022.
- S: pain (use pain score)
- O: relate findings to the process of inspection, palpation,
auscultation, percussion. “no masses on palpation” “tympanic
membranes are pearly gray”
- O: Use anatomic landmarks to add precision
- O: Findings that vary by degrees are customarily graded or
recorded in an incremental scale format (pulse amplitude, heart
murmur intensity, muscle strength, DTR
- Illustrations useful in describing the origin of pain and where it
radiates and the size, shape and location of a lesion
- HX of present illness: OLDCARTS: onset, location, duration,
character, aggravating factors, relieving factors, temporal factors,
severity of symptoms
•Ethical decision making and beneficence
- Beneficence: doing good
Diversity and Health Assessment – Bullets 6, 7,
8 Cultural Awareness and Diversity
Achieving cultural competence is a learning process that requires self-
awareness, reflective practice, and knowledge of core cultural issues
A culturally competent health care provider adapts to the unique
needs of patients of backgrounds and cultures that differ from his or
her own
Culture, in its broadest sense, reflects the whole of human behavior,
including ideas and attitudes; ways of relating to one another;
manners of speaking; and the material products of physical effort,
ingenuity, and imagination.
The stereotype, a fixed image of any group that denies the potential of
originality or individuality within the group
Multiple studies have shown that health care providers activate these
implicit stereotypes, or non-conscious bias, when communicating with
and providing care to minority patients
Members of racial and ethnic groups are not uniform. Each group is
highly heterogeneous and includes a diverse mix of immigrants,
refugees, and multigenerational Americans who have vastly different
histories, languages, spiritual practices, demographic patterns, and
cultures
Culturally competent care requires that health care providers be
sensitive to patients' heritage, sexual orientation, socioeconomic
situation, ethnicity, and cultural background
When cultural differences exist, be certain that you grasp exactly what
the patient means and know exactly what the patient thinks you mean
in words and actions The definition of “ill” or “sick” is based on the
individual's belief system and is determined in large part by his or her
enculturation.
, Health assessment midterm study guide2021-2022.
Socioeconomic, spiritual, and lifestyle factors affecting diverse populations
