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Health History/Subjective Data - CORRECT ANSWERS ✔✔Past
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medical history (PMH) |\ |\
Family History |\
Personal/Social History |\
History of Present Illness (HPI); including 8 dimensions of any
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positive symptoms |\
Review of Symptoms |\ |\
BMI calculation - CORRECT ANSWERS ✔✔weight in kg/height in
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meters^2
temperature - CORRECT ANSWERS ✔✔oral, temporal or typanic |\ |\ |\ |\ |\ |\ |\
documentation of pulse - CORRECT ANSWERS ✔✔P 58, regular |\ |\ |\ |\ |\ |\ |\ |\ |\
rate & rhythm; if irregular listen apically
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resp rate documentation - CORRECT ANSWERS ✔✔RR 16, ease,
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regular (or labored, etc.) |\ |\ |\
open ended questions - CORRECT ANSWERS ✔✔try not to put
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words in the pt. mouth
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ask what brings you in today? rather than i see you have ab pain
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tell me about that
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, types of health histories - CORRECT ANSWERS ✔✔comprehensive
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- all
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interval - since the last I saw you|\ |\ |\ |\ |\ |\ |\
focused - really focused on CC; SOB for example or more for a
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follow up visit |\ |\
emergent - tell me what's happening right now (ED for example)
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current health status - CORRECT ANSWERS ✔✔medications what
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and why |\
allergies and response to them (anaphylaxis, etc.)
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date of last exam remind they may be up for immunizations
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past medical history - CORRECT ANSWERS ✔✔info on pts. health
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status from birth to present
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childhood illness/immunizations |\
medical illnesses - chronic or episodic
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