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These vocabulary flashcards cover communication stakeholders, medical models, history-taking acronyms, documentation formats, and health literacy concepts based on the lecture notes.
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HCAHPS
The Hospital Consumer Assessment of Healthcare Providers and Systems; the first national, standardized, publicly reported survey of patients' perspectives of hospital care.
Medical Model
A model of thought that focuses on the injury alone, viewing it as a defect that needs to be fixed.
Disablement Model
A model of thought that sees the person as a whole and examines how an injury impacts functional limitations, ADLs, career, and social barriers.
HOPS
An evaluation process acronym standing for History, Observation, Palpation, and Special Tests.
HIPS
An evaluation process acronym standing for History, Inspection, Palpation, and Special Tests.
SOCRATES
An acronym for pain history: Site, Onset, Character, Radiation, Associations, Time course, Exacerbating/relieving factors, and Severity.
Presenting Complaint (PC)
What the patient tells the provider is wrong, such as "chest pain."
Past Medical History (PMH)
Information gathered about a patient's other medical problems outside of the current complaint.
Drug History (DH)
Information regarding medications, dosages, frequency, allergies, OTC medications, herbal supplements, and birth control.
Family History (FH)
Information about genetic conditions or diseases within the family, such as diabetes or cardiac history.
Social History (SH)
Background information including smoking, alcohol, illegal substances, living situation, driving status, and sexual history.
Review of Systems (ROS)
A cephalocaudal review of body systems including CVS, Respiratory, GI, Neurology, Genitourinary, Musculoskeletal, Psychiatry, and ENT.
ICE
An acronym used during the summary of history to address the patient's [I]deas, [C]oncerns, and [E]xpectations.
SOAP Note
A format for recording treatment information consisting of Subjective, Objective, Assessment, and Plan.
Subjective (SOAP)
The portion of a note describing impressions of the patient or the patient's own report of their symptoms and responses to interventions.
Objective (SOAP)
The section reporting measurable and observable information obtained during a treatment session.
Assessment (SOAP)
The descriptive assessment of the client's performance and progress toward goals during a session.
Plan (SOAP)
The outline for the course of treatment, upcoming sessions, and home programs for the patient.
Health Literacy
The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.
Teach-Back Method
A strategy to confirm patient understanding by asking them to repeat or explain back the health information provided.
Plain Language
The use of simple, concrete terms instead of complicated medical jargon to improve patient communication and understanding.