The Medical History & the Interview

Vocabulary flashcards covering key terms, clinical concepts, and medical documentation from Chapter 2 of Wilkins' Clinical Assessment in Respiratory Care.

Medical History

The foundation of a comprehensive assessment that provides a written, organized, unbiased, detailed, and chronologic description of a patient's perception of their past or present health status, family lifestyle, and symptom development.

Subjective Data

Information that the patient reports, feels, or experiences that cannot be perceived by an observer.

Objective Data

Information that can be seen, felt, smelled, or heard by the examiner during a physical examination, commonly referred to as signs.

Reflecting (or Echoing)

An interview technique of repeating certain words the patient just used to stimulate further input from the patient.

Review of Systems (ROS)

A recording of past and present subjective information grouped by body or physiologic systems that may be relevant to the present problem but might otherwise have been overlooked.

Pertinent Negative

Negative responses to important questions asked at any time during the medical history interview (for example, denying a fever when complaining of an acute cough).

Pertinent Positive

Affirmative responses to important questions asked during the medical history interview (for example, complaining of an acute cough).

Signs

Objective manifestations of disease obtained during the physical examination that can be seen, felt, smelled, or heard by the examiner.

Symptoms

Subjective manifestations of disease that are evident only to the patient and cannot be perceived by an observer.

Chief Complaint (CC)

A brief notation explaining why the patient sought health care, where each symptom is recorded separately with its duration or date of initial occurrence.

History of Present Illness (HPI)

The narrative portion of the medical history that chronologically and in detail describes each symptom listed in the Chief Complaint and its effect on the patient's life.

Pack-Years

A measurement unit for cigarette consumption calculated as: $\text{Pack-years} = \text{number of years smoked} \times \text{number of packs smoked per day}$

Admission Note

A narrative description written by the admitting physician that details the patient's baseline status upon admission, why they were hospitalized, current condition, and initial treatment plan.

Physician Orders

A section of the patient's chart where the admitting physician lists the specific treatment plan and monitoring techniques required to care for the patient.

Progress Notes

Daily chart documentation made by physicians and other health care professionals following patient visits to document examination findings, progress, and response to treatment.

Advance Directive

A legal document in which individuals specify what actions should be taken for their health if they are no longer able to make decisions for themselves due to illness or incapacity.

Do Not Resuscitate (DNR)

A physician's order and chart label alerting the care team that resuscitation should not be attempted if the patient experiences respiratory or cardiac arrest.

Do Not Intubate (DNI)

A variation of DNR orders that prohibits intubation while allowing the administration of certain CPR medications such as epinephrine or atropine.