and answers latest update
What are the components of a COMPLETE health assessment? - ANSWER- CC, HPI,
PMH, FH, Social Hx, ROS, Genogram
What are the components of a FOCUSED health assessment? - ANSWER- CC, HPI,
PMH, FH/SH that pertains to complaint, specific system ROS
Foundation of the HPI is the PQRST format; what does it stand for? - ANSWER-
Provocative
Quality or Quantity
Region/Radiation
Severity
Timing
Provocative Components - ANSWER- What causes the symptom
What makes it worse or better?
What do you do for it? Meds/rest?
Looking for triggers, relievers, aggravators
Quality or Quantity Components - ANSWER- How does it feel, look, sound, or smell?
How much are you experiencing now?
Does it interfere with ADLs?
Is it worse, better, or different than the last time?
Region/Radiation - ANSWER- Where is it located?
Does it travel anywhere else in your body?
Severity - ANSWER- On a scale of 1 - 10, how bad is it?
At its worse do you have to sit down, lie down, or slow down?
Is it getting better, worse, or the same?
Timing - ANSWER- When did it begin? Date/time?
Type of onset - how did it start? Suddenly or gradually
Frequency - how often does it occur? When does it occur? What time of day? Does it
wake you up? Does it happen after/before food? Seasonal?
Duration - how long does it last?
What is the most important question to ask? - ANSWER- Have you ever had this
before???
What are the components of a PMH? (past med hx) - ANSWER- Childhood/adult illness
Surgeries with dates
Immunizations
, Pediatric, adolescent, and adult
Serious injury/trauma - transfusions
Medications
Prescription
OTC
Allergies and response
Screening exams
Psychiatric/mental health issues
What are the components of FH? (family history) - ANSWER- CAD, cholesterol
DM
HTN, stroke
CA
TB
Asthma
Bleeding, anemia
Alcoholism
Weight, mental health
What are the components of Social History? - ANSWER- Alcohol/Drugs
Occupation
Nutrition
Exercise
Home life/support system/housing/safety/SES
Exposures/travel
Stress management
Sleep
What are the components of a ROS? (review of systems) - ANSWER- Head to toe
Complete systematically
Documentation - Pt opportunity to address problems, NOT physical component,
Pertinent negative (or positive), Denies chest pain , sob
Never write as "no problems"
Pertinent positives/negatives
What are the components to a genogram? - ANSWER- 3 generational, points out risk
factors, allows for anticipatory guidance
What is the screening tool that focuses on detecting pts at high risk for an eating
disorder? - ANSWER- SCOFF
S-Do you make yourself Sick when you feel uncomfortably full?
C-Do you worry you have lost Control over how much you eat?
O-Have you recently lost more than One stone (14 lbs.) in a 3-month period?
F-Do you believe yourself to be Fat when others say you are too thin?