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person-first language
a destigmatizing communication style that emphasizes the person and views the disorder, diseases, condition, or disability as only one part of the whole person
health care record
4 purposes of a ____ _____ ____
clinical care and continuity
communication
legal document
quality assurance and improvement
Hx
Abbreviation for history
PI
abbreviation for present illness
HPI
abbreviation for history of present illness
Sx, SXS
abbreviation for symptoms
CC
abbreviation for chief complain
c/o
abbreviation for complaints of
PH
abbreviation for past history
PMH
abbreviation for past medical history
s/p
abbreviation for surgical operations
UCHD
abbreviation for unusual childhood disease
NKA
abbreviation for no known allergies
NKDA
abbreviation for no known drug allergies
FH
abbreviation for family history
SH
abbreviation for social history
OH
abbreviation for occupational history
ROS
abbreviation for review of symptoms
SR
abbreviation for systems review
review of symptoms (ROS), systems review (SR)
head to toe review of the function of all body systems; evaluate symptoms not previously mentioned
PE
abbreviation for physical examination
Px
abbreviation for physical
vital signs
objective evidence of disease (blood pressure, pulse, respirations, temperature, height, weight, O2 saturation)
blood pressure, pulse, respirations, temperature, height, weight, O2 saturation
Name 7 vital signs
HEENT
abbreviation for head, eyes, ears, nose, throat
head, eyes, ears, nose, throat
What does HEENT stand for?
PERRLA
abbreviation for pupils equal, round, and reactive to light and accommodation
NAD
abbreviation for no acute distress
WNL
abbreviation for within normal limits
WF
abbreviation for within functional limits
IMP
abbreviation for impression
Dx
abbreviation for diagnosis
A
abbreviation for assessment
differential diagnosis
when one or more diagnoses are considered
R/O
abbreviation for rule out
P
abbreviation for plan
subjective (S), objective (O), assessment (A), plan (P)
What are the components of a SOAP note?
subjective (S)
component of SOAP note that includes client’s report of limitations, concerns, and problems, as well as what the client said that was relevant to treatment, such as significant complaints of pain, or other expressions of feelings, attitudes, concerns, goals, and plans
objective (O)
component of SOAP note that includes measurable, quantifiable, and observable data obtained during the session; presents a picture of the skilled session provided
assessment (A)
component of SOAP note that includes appraisal of the client’s occupational performance limitations, progress, and expected benefit from occupational therapy services based on subjective (S) and objective (O) sections via clinical reasoning; addresses problems, progress, and potential
plan (P)
component of SOAP note that includes anticipated frequency and duration of services and the specific interventions that will be used to achieve client’s goals based on objective (O) and assessment (A) sections
problems, progress, potential
What are the “3 Ps” of the assessment component of a SOAP note?
subjective (S), objective (O)
What two components of the SOAP note serve as the basis for the assessment (A) section?
objective (O), assessment (A)
What two components of the SOAP note serve as the basis for the plan (P) section?
drug
chemical entities (both endogenous and foreign) that are capable of interacting with biological systems
chemical, generic (nonproprietary, official), trade (proprietary)
What are the three names that each drug can be identified by?
chemical
drug name based on specific compound structuregne
generic (nonproprietary, official)
drug name derived from the chemical name; preferred
nonproprietary, official
What are other terms for “generic” drug name
generic, official
What are other terms for “nonproprietary” drug name
generic, nonproprietary
What are other terms for “official” drug name
trade (proprietary)
drug name assigned by drug manufacturer
proprietary
What is another term for “trade” drug name
trade
What is another term for “proprietary” drug name
generic (nonproprietary, official)
What is the preferred drug name
pharmacology
study of the interaction of chemical (e.g., drugs) with biological systems
pharmacokinetics, pharmacodynamics, therapeutics, toxicology
What are the 4 divisions of pharmacology?
pharmacokinetics
1 of 4 divisions of pharmacology; study of the absorption, distribution, metabolism, and excretion of drugs
absorption, distribution, metabolism, excretion
What does “ADME” stand for in pharmacokinetics?
pharmacokinetics
“ADME” applies to which division of pharmacology? (pharmacokinetics, pharmacodynamics, therapeutics, toxicology)
absorption, distribution, metabolism, excretion (ADME)
What are the four aspects of pharmacokinetics?
pharmacodynamics
1 of 4 divisions of pharmacology; study of the biochemical and physiological effects of drugs and their mechanism of action
therapeutics
1 of 4 divisions of pharmacology; use of drugs in the prevention, diagnosis, and treatment of disease
toxicology
1 of 4 divisions of pharmacology; study of the adverse effects of drugs
pharmacokinetics
Which division of pharmacology can be described as “How does the body change the drug?”
pharmacodynamics
Which division of pharmacology can be described as “How does the drug change the body?”
pharmacokinetics
Which division of pharmacology can be described as “What does the body do to the drug?”
pharmacodynamics
Which division of pharmacology can be described as “What does the drug do to the body?”
enteral
What is the most common route of drug administration?
enteral
route of drug administration that involves passage of drugs into the alimentary tract
alimentary
Enteral route of drug administration involve passage of drugs into the _____ tract.
parenteral
route of drug administration that bypasses the alimentary tract
enteral, parenteral
What are the two main categories of routes of drug administration?
enteral
The following routes of drug administration are ____ routes:
oral
rectal
buccal
sublingual
(enteral or parenteral)
oral, rectal, buccal, sublingual
Name 4 enteral routes of drug administration
oral (has to be absorbed by stomach and small intestine; other routes are absorbed directly into the blood stream)
What is the slowest enteral route of drug administration?
sublingual (enteral)
Nitroglycerin tablets for angina are administered via what route?
parenteral
The following routes of drug administration are ____ routes:
intravenous (i.v.)
intramuscular (i.m.)
subcutaneous (s.c.)
intraperitoneal (i.p.)
intraarterial (i.a.)
intrathecal
intradermal
(enteral or parenteral)
intrathecal
parenteral route of administration that involves injection of the drug within a sheath (e.g., the spinal subarachnoid space)
intravenous, intramuscular, subcutaneous, intraperitoneal, intraarterial, intrathecal, intradermal
Name 7 examples of parenteral routes of drug administration
parenteral
The following disadvantages describe ______ routes of drug administration.
Increased risk of infection
Irreversibility of administered drug
May be painful
Skilled personnel may be required
(enteral or parenteral)
parenteral
The following advantages describe ______ routes of drug administration.
May be used in emergency situations
Suitable for unconscious patients
High bioavailability
Control of delivered dose of drug
(enteral or parenteral)
enteral
The following advantages describe ______ routes of drug administration.
Safe
Fast, non-injectable
Cheap
Does not require skilled personnel
(enteral or parenteral)
enteral
The following disadvantages describe ______ routes of drug administration.
Variation in rate of absorption
Problems with patient compliance
(enteral or parenteral)
transdermal
route of drug administration in which drug is applied directly to the surface of the skin and absorbed through the dermal layers; ensures slow controlled release of drug into body
iontophoresis
transdermal route of administration in which electric current is used to drive ionized drug through the skin
phonophoresis
transdermal route of administration in which ultrasound waves are used to enhance transmission of drug through the skint
transdermal
Iontophoresis and phonophoresis are _____ routes of drug administration.
iontophoresis, phonophoresis
Name 2 transdermal routes of drug administration
False
True of false: drugs administered topically are intended for systemic use.
True
True of false: drugs administered transdermally are intended for systemic use.
transdermal
Which of the following routes of administration are intended for systemic use: transdermal, topical
topical
route of drug administration in which drug is applied to various mucous membranes and skin; not intended for systemic usein
inhalation
route of drug administration in which gaseous or volatile drug is absorbed from the respiratory tract
absorption
aspect of pharmacokinetics which describes the rate at which a drug leaves the site of administration and the extent to which this occurs
absorption
The following factors affect drug ______:
drug solubility
blood flow to site of absorption
route of administration
(absorption, distribution, metabolism, excretion)
distribution
aspect of pharmacokinetics which describes the delivery of drug from systemic circulation to tissues
fat, bone
Name 2 examples of storage depots in which drugs may be sequestered.
False (drugs may be sequestered in storage depots such as fat and bone)
True or false: drugs are uniformly distributed in body tissues.
The following factors affect drug ______:
Drug sequestration
Blood flow
Tissue permeability
Extent of protein binding
(absorption, distribution, metabolism, excretion)