The Medical Record and Health History LO #6

What is the collection of subjective data about the pt?

health history report

Pt completes a ___ form, then it's reviewed for completeness by ___.

preprinted, medical assistant

Who is thorough patient history taken for?

each pt

What is the determination of pt general state of health, arrival of a general diagnosis, prescribe tx, document change in pt illness after tx?

use of health history

What is the scientific method of determining & identifying a pt's condition?

diagnosis

If an office uses EMR, the pt will fill out hx on paper yet who enters the data into their medical record?

medical assistant

What are two ways the MA can enter pt hx?

enter info while asking questions, enter info later after the conversation

What must be provided for a pt to complete a questionnaire in the office?

a quiet and private area

When is health history taken?

before physical exam

What does health history provide the Dr. an opportunity to do?

compare findings

What are the sections to health history?

identification data, chief complaint, present illness, past history, family history, social history

Where is the identification data located on a pt history form nd what does it obtain?

the beginning and basic demographic info

Who completes the identification data?

the pt

What does the chief complaint identify?

pt's reason for seeking care

What is the chief complaint used as a foundation for?

obtaining the present illness and review of systems section

Who is responsible for completing the chief complaint info?

medical assistant

What questions should be asked when documenting the chief complaint?

open ended questions

What should the chief complaint be limited to?

one to two specific sx and duration of sx

What should the MA avoid using when documenting chief complaint?

names of diseases or diagnostic terms

The present illness is the expansion of what?

chief complaint

Who is responsible for completing the present illness section?

medical assistant

Where is the present illness documented?

same form as CC or into EMR

With PI the MA is asking questions to obtained a detailed description of the symptom causing what?

the greatest problem

What's an abbreviation to help with PI?

OPPQRRSSTA

What do the letters in the abbreviation stand for?

onset (when did it start), palliative (relieve pain), provocative (makes worse), quality, rate, radiation/referral, site, setting, timing, association sx

What does past history assist the Dr. with?

providing optimal care for current problem

Who completes the past history, and on what type of form?

pt on a health history type form

What is the MA addressing when asking questions such as major illnesses, childhood diseases, unusual infections, accidents + injuries, hospitalizations + operations, previous medical test, immunizations, allergies, current medications?

past history

What's an abbreviation for past history?

THISMEAD

What do the letter in the abbreviation stand for past history?

traumas, hospitalizations, illnesses/immunizations/childhood diseases/infections, surgeries, medications, examinations, allergies, diagnostic testing

Family history is the review health status of a pt's who?

blood relatives

Family history focuses on diseases that tend to be what?

familial diseases

What are examples of familial diseases?

hypertension, heart disease, allergies, diabetes mellitus

Who usually completes the family history and what must they provide?

the pt and state of health, presence of any significant disease, if deceased cause of death

What can also be done or added for family history?

genogram and age of death if deceased

Social history includes info on the pt's what?

lifestyle

What does social history provide info regarding?

effect illness may have on pt's daily living

Major lifestyle adjustments may warrant what?

support services

Who is the social history completed by and what is included?

the pt and education, occupation, living environment, diet, personal history, exercise

What is an abbreviation for social history?

DEARHOSSSSSF

What does the abbreviation stand for in social history?

diet, exercise, alcohol (how much), recreation drugs, hobbies, occupation, stress, sex, smoking (how much), sleep (does pain wake up), seatbelt (do you wear it), firearms (weapons in home)

What an abbreviation for additional info that may be asked in pt history?

GNCPICGRREENHAM

What does the additional info abbreviation stand for?

gastrointestinal, neurological, cardiovascular, psychological, integumentary, constitutional (overall feeling), genitourinary, respiratory, reproductive, eyes/ears/noes/throat/mouth, endocrine, neck, hematological, allergies, musculoskeletal