Advanced Health Assessment
What are the concepts of developing a relationship with the patient? - ANSWER
See the patient as a unique individual
Let them know that you really want to know all that is needed
Be open and flexible
Explain boundaries
Be honest
What is the primary objective when developing a relationship with the patient? -
ANSWER To discover the details about a patient's concern, explore expectations,
display interest, and partnership
What does establishing a positive relationship with the patient depend on? -
ANSWER Communication built on courtesy, comfort, connection, and confirmation.
What are effective communication strategies when obtaining a health history? -
ANSWER Using open-ended questions, direct questions, rarely leading questions.
Facilitate by encouraging patient to say more. Reflect by repeating what you heard.
Clarify. Empathize by showing understanding and acceptance. Confront by
discussing disturbing behavior. Interpret by repeating what you heard to confirm.
What are open-ended questions? - ANSWER Those that give the patient discretion
about the extent of the answer. Such as "How have you been feeling?" or "What
brings you in today?"
What are direct questions? - ANSWER Those that seek specific information. Such
as "How long ago did that happen?" or "Where does it hurt?"
What are leading questions? - ANSWER Those that are prompting the patient
toward the desired answer and these are the most risky.
What is a patient centered question? - ANSWER One that respects and responds to
a patient's wants, needs, preferences so that they can make choices in their care
that best fit their individual circumstances. Such as "How would you like to be
addressed?", "What would you like us to do today?", "How are you coping with your
illness?".
What are potential barriers of patient and provider communication? - ANSWER
When the patient is curious about you, anxiety, silence, depression,
crying/compassionate moments, physical & emotional intimacy, seduction, anger,
avoiding the full story, financial considerations.
What is the structure and components of the patient history? - ANSWER Patient
identifiers, chief complaint, history of present illness, past medical history, family
history, personal/social history, review of systems
,What kind of patient information is obtained in the patient identifier component of the
patient history? - ANSWER name, age, gender, race, occupation, date, time, and
referral source
What kind of patient information is obtained in the chief complaint component of the
patient history? - ANSWER a brief statement about why the patient is seeking care
while probing for underlying concerns.
What kind of patient information is obtained in the HPI component of the patient
history? - ANSWER a chronological order of events leading up to the presenting
problem, health status prior to the onset, a complete description of first symptoms,
symptom analysis (onset, location, description, duration, intensity, character,
aggravating factors, alleviating factors), impact on patients lifestyle, medications or
treatments tried
What kind of information is obtained in the PMH component of the patient history? -
ANSWER general health/strength
childhood illnesses
major adult illnesses and chronic diseases
immunization
surgeries (dates, hospital, diagnosis, complications)
serious injuries resulting in disability
limitation of ability to function d/t past events
medications
allergies (meds, environment, seasonal, food)
transfusions
recent screening tests
emotional status
What kind of information is obtained in the family history component of the patient
history? - ANSWER Any relevant medical problems for both immediate and non-
immediate family members
What kind of information is obtained in the personal/social history section of the
patient history? - ANSWER home environment and conditions (pets, economic)
where was the patient raised
education
position in family
marital status
life satisfaction
hobbies/interests
source of stress
habits (nutrition, sleep, drugs, etoh, ADL's, and smoking)
self-care (self breast exams, exercise, home remedies)
sexual history
environmental (travel, exposure to diseases)
religious and cultural preferences
access to care
, What information is necessary when obtaining sexual health information? -
ANSWER number of partners, concerns, birth control, protection from STI's
What kind of information is obtained for the ROS component of the patient history? -
ANSWER those that identify presence or absence of health related issues in each
body system
What is subjective data? - ANSWER it is information collected during the patient
interview with the patient or significant other. it is their words. It can include
symptoms, sensations, feelings, perceptions, desires, preferences, beliefs, ideas,
values, personal information, ROS, complete health history
What is objective data? - ANSWER it is the information that can be physically seen
by the provider and tested against. It can include the physical exam, lab analysis, x
rays, and professional consults.
How do you approach sensitive issues when interviewing a patient? - ANSWER
Provide privacy, be direct and firm, don't ask leading questions, use open-ended
questions, don't apologize for asking questions, don't preach, avoid confrontation,
use understandable language, watch medical jargon, document carefully using the
patient's words.
What does it mean to be culturally aware? - ANSWER It is the deliberate self-
examination and in depth exploration of one's own biases, stereotypes, prejudices,
assumptions that one holds about people different than them.
What does it mean to be culturally competent? - ANSWER It requires the provider to
be sensitive to a patient's heritage, sexual orientation, socioeconomic situation,
ethnicity, and cultural background
What are examples of questions that explore the patient's culture? - ANSWER "what
do you call your problem?"
"What do you think caused it?"
"What does your sickness do to you?"
"Why do you think it started when it did?"
"What should be done to get rid of it?"
"Who else or what else might help you get better?"
What are the components of a cultural response to a patient? - ANSWER the
response should include modes of communication to include speech, space, and
body language, awareness of the the patients health beliefs, diet and nutritional
practice, and the nature of relationships with their family
How do you measure visual acuity and test CN II - ANSWER by measuring
distance, near vision , and peripheral vision
What is CN II? - ANSWER optic nerve
What are the concepts of developing a relationship with the patient? - ANSWER
See the patient as a unique individual
Let them know that you really want to know all that is needed
Be open and flexible
Explain boundaries
Be honest
What is the primary objective when developing a relationship with the patient? -
ANSWER To discover the details about a patient's concern, explore expectations,
display interest, and partnership
What does establishing a positive relationship with the patient depend on? -
ANSWER Communication built on courtesy, comfort, connection, and confirmation.
What are effective communication strategies when obtaining a health history? -
ANSWER Using open-ended questions, direct questions, rarely leading questions.
Facilitate by encouraging patient to say more. Reflect by repeating what you heard.
Clarify. Empathize by showing understanding and acceptance. Confront by
discussing disturbing behavior. Interpret by repeating what you heard to confirm.
What are open-ended questions? - ANSWER Those that give the patient discretion
about the extent of the answer. Such as "How have you been feeling?" or "What
brings you in today?"
What are direct questions? - ANSWER Those that seek specific information. Such
as "How long ago did that happen?" or "Where does it hurt?"
What are leading questions? - ANSWER Those that are prompting the patient
toward the desired answer and these are the most risky.
What is a patient centered question? - ANSWER One that respects and responds to
a patient's wants, needs, preferences so that they can make choices in their care
that best fit their individual circumstances. Such as "How would you like to be
addressed?", "What would you like us to do today?", "How are you coping with your
illness?".
What are potential barriers of patient and provider communication? - ANSWER
When the patient is curious about you, anxiety, silence, depression,
crying/compassionate moments, physical & emotional intimacy, seduction, anger,
avoiding the full story, financial considerations.
What is the structure and components of the patient history? - ANSWER Patient
identifiers, chief complaint, history of present illness, past medical history, family
history, personal/social history, review of systems
,What kind of patient information is obtained in the patient identifier component of the
patient history? - ANSWER name, age, gender, race, occupation, date, time, and
referral source
What kind of patient information is obtained in the chief complaint component of the
patient history? - ANSWER a brief statement about why the patient is seeking care
while probing for underlying concerns.
What kind of patient information is obtained in the HPI component of the patient
history? - ANSWER a chronological order of events leading up to the presenting
problem, health status prior to the onset, a complete description of first symptoms,
symptom analysis (onset, location, description, duration, intensity, character,
aggravating factors, alleviating factors), impact on patients lifestyle, medications or
treatments tried
What kind of information is obtained in the PMH component of the patient history? -
ANSWER general health/strength
childhood illnesses
major adult illnesses and chronic diseases
immunization
surgeries (dates, hospital, diagnosis, complications)
serious injuries resulting in disability
limitation of ability to function d/t past events
medications
allergies (meds, environment, seasonal, food)
transfusions
recent screening tests
emotional status
What kind of information is obtained in the family history component of the patient
history? - ANSWER Any relevant medical problems for both immediate and non-
immediate family members
What kind of information is obtained in the personal/social history section of the
patient history? - ANSWER home environment and conditions (pets, economic)
where was the patient raised
education
position in family
marital status
life satisfaction
hobbies/interests
source of stress
habits (nutrition, sleep, drugs, etoh, ADL's, and smoking)
self-care (self breast exams, exercise, home remedies)
sexual history
environmental (travel, exposure to diseases)
religious and cultural preferences
access to care
, What information is necessary when obtaining sexual health information? -
ANSWER number of partners, concerns, birth control, protection from STI's
What kind of information is obtained for the ROS component of the patient history? -
ANSWER those that identify presence or absence of health related issues in each
body system
What is subjective data? - ANSWER it is information collected during the patient
interview with the patient or significant other. it is their words. It can include
symptoms, sensations, feelings, perceptions, desires, preferences, beliefs, ideas,
values, personal information, ROS, complete health history
What is objective data? - ANSWER it is the information that can be physically seen
by the provider and tested against. It can include the physical exam, lab analysis, x
rays, and professional consults.
How do you approach sensitive issues when interviewing a patient? - ANSWER
Provide privacy, be direct and firm, don't ask leading questions, use open-ended
questions, don't apologize for asking questions, don't preach, avoid confrontation,
use understandable language, watch medical jargon, document carefully using the
patient's words.
What does it mean to be culturally aware? - ANSWER It is the deliberate self-
examination and in depth exploration of one's own biases, stereotypes, prejudices,
assumptions that one holds about people different than them.
What does it mean to be culturally competent? - ANSWER It requires the provider to
be sensitive to a patient's heritage, sexual orientation, socioeconomic situation,
ethnicity, and cultural background
What are examples of questions that explore the patient's culture? - ANSWER "what
do you call your problem?"
"What do you think caused it?"
"What does your sickness do to you?"
"Why do you think it started when it did?"
"What should be done to get rid of it?"
"Who else or what else might help you get better?"
What are the components of a cultural response to a patient? - ANSWER the
response should include modes of communication to include speech, space, and
body language, awareness of the the patients health beliefs, diet and nutritional
practice, and the nature of relationships with their family
How do you measure visual acuity and test CN II - ANSWER by measuring
distance, near vision , and peripheral vision
What is CN II? - ANSWER optic nerve
