Patient Interactions & History Taking - Key Terms

advanced directives

legal document prepared by a living, competent adult to provide guidance to the health care team if the individual should become unable to make decisions regarding their medical care

AIDET

acknowledge, introduce, duration, explanation, thank you

ambulate

the ability to walk

chief complaint

primary medical problem as defined by the patient

chronology

time element of the history, usually including the onset, duration, frequency, and course of symptoms

clinical history

information available regarding a patient's condition

communication

exchange of information, thoughts, or messages

DABDA

denial, anger, bargaining, depression, acceptance

emotional intelligence

ability to evaluate, perceive, and control emotions

gerotonology

pertaining to the study of older adults

inpatient

someone who has been admitted to the hospital for diagnostic studies or treatment

leading questions

undesirable method of questions; provides information that may direct answers toward a suggested symptom or complaint

localization

determination of precise area, usually through gentle palpation or careful wording of questions

manage up

certification/licensure, years of experience, number of exams

maslow's hierarchy of needs

model of human needs

nonverbal communication

exchange of information, thoughts or messages using methods other than the actual words of speech

objective

perceptible to the external senses

outpatient

patient who comes to a health care facility for diagnosis or treatment but does not occupy a bed overnight

palpation

application of light pressure with the fingers

paralanguage

music of language; cadence and rhythm of speech

patient assessment

objective evaluation and determination of the status of a patient

patient autonomy

ability and right of patients to make independent decisions regarding their medical care

personal hygiene

non-verbal communication; make yourself presentable and professional

physical prescence

non-verbal communication; posture and facial expression

professional appearance

un-kept appearance may cause patient to feel as though professional and technique may also be unkept

quality

character of the symptoms; acute or chronic

subjective

pertaining to or perceived only by the affected individual; not perceptible to the senses

touch

non-verbal communication; emotional support, emphasis, palpation

verbal communication

messages sent using spoken words

visual contact

non-verbal communication; eye contact