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biophysical
the science of applying physcial laws and theeories of biologic problems
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cognitive
pertaining to the operation of the mind, the process by which we become aware of perceiving , thinking and remembering
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congruence
agreement, the state that occurs when verbal expression of the message mathces the sender's nonverbal body language
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familial
occuring in or affecting members of a family more than would be expected by chance
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present illness
the chief compaint, written in chronologic sequence with dates of onset
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psychosocial
peraining to a combination of psychological and social factors
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rapport
a relationship of harmony and accord between the patient and the healthcare professional
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signs
. objective findings determined by a clinician such as a fever, hypertenision or rash
. something that can be measured , inspected ( to see), palpated(touch), auscultated or manipulated(move)
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symptoms
. subjective complaints reported by the patient such as pain or visual disturbances , nausea, dizziness
- . patients complaints regarding how he or she feels
- . measures pain on scale of 1 to 10
- . cardinal symptoms are those most helpful in diagnosis
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holistic care
. includes assessing the patient's health status with physcial, cognitive, psychosocial and behavioral data
. the whole patient
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PMH
- past medical history
- . previous health
- . usual childhood diseases, allergies, surgeries , accidents and immunization record
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SH
- social history
- . lifestyle
- . occupation
- . hobbies
- . education
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ROS
- review of systems
- . help detect conditions other than those covered under the present illness
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empathy
. is the key to creating a caring therapeutic environment
. requires those in healthcare services to examine their own values, beliefs , and actions
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listening must be an active process in a therapeutic relationship such as
- . restatement
- . reflection
- . clarification
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nonverbal communication
. approximately 90% of patient interactions occur through nonverbal language
. successful patient interaction has congruent verbal and nonverbal messages.
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preparing the appropriate environment
- . ensure privacy
- . refuse interruptions
- . prepare comfortable surroundings
- . take judicious notes
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open-ended questions
. gives the patient the opportunity to provide additional information
- . " what brings you to the doctor?"
- . " how have you been getting along?"
- . " you mentioned having dizzy spells. tell more about that
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closed-ended questions
. asked for specific information that can be answered with only a few words
- . do you have a headache?
- . what is your birthdate?
- . have you ever broke a bone?
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interviewing the patient contract between the medical assistant and patient three parts
- . initiation or introduction
- . the body
- . the closing
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interview barriers
- . providing unwarranted assurance
- . giving advice
- . using medical terminolgy
- . asking leading questions
- . talking too much
- . using defense mechanisms
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POMR
promblem-oriented medical record
- . logical sequence to recording
- . database
- . problem list
- . plan
- . progress notes
- . use SOAPE format to define the patient's health problems
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s
- . subjcetive data
- . chief complaint in patients words
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o
- . objective data
- . anything that is observed or measurable
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a
- . assessement
- . physician's tentative diagnosis
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p
- . plan of care
- . physician documents how health problem will be managed
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e
- . evaluation
- . assessment of treatment outcome
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new diagnosis is called
differentiated diagnosis
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database
the record of patient name, address, date of birth, insurance information, personal data , history, physical exam, and initial laboratory findings
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progress notes should include
- . the purpose of the visits written as chief complaint
- . vital signs
- . pain report 1 to 10
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denial
the patient completely rejects the information
. I couldn't possible have breast cancer. you must mistaken
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suppression
the patient is consciously aware of the infromation or feeling but refuses to admit it
. I don't think the test is accurate. my mammogrames are always normal
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reaction formation
the patient expresses her feelings as the opposite of what she really feels
. I appreciate your trying to help me but I just can't come to the hospital that day
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projection
the patient accuses someone else of having the feeling that she has
. you don't have to lose your temper about this
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rationalization
the patient comes up with varous explanations to justify her response
. I think the results are wrong I didn't follow the directions for the test like I should have besides there's no history of breast cancer in my family
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undoing
the patient tries to reverse a negative feeling by doing something that indicated the opposite feeling
. don't worry dear i'm not upset with for telling me about this
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regression
the paitent reverts to an old usually immature behavior to ventilate her feelings
. I can't possibly schedule a procedure without discussing this with my mother
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sublimation
the patient redirects her negative feelings into a socially productive activity
. becoming a member of local support group
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cardinal symptoms
symptoms of the greatest significanace in identifying a disease
- . crushing chest pain
- . difficulty breathing
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SOMR
. source-oriented medical record organizes patient data into specific sections
. filed in reverse chronologic order with the most recent report or progress note on top
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EMR
- . electronic medical record
- . use passwords
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patient education
the perfect time to initiate patient education is during the initial patient interview
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kubler-ross 5 stages of dying
Denial "This is not happening to me.
- Anger: "How dare God do this to me."
- Bargaining
: "Just let me live to see my son graduate." - Depression:
"I can't bear to face going through this, putting my family through this."- Acceptance
: "I'm ready, I don't want to struggle anymore."
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