chapter 28

  1. biophysical
    the science of applying physcial laws and theeories of biologic problems
  2. cognitive
    pertaining to the operation of the mind, the process by which we become aware of perceiving , thinking and remembering
  3. congruence
    agreement, the state that occurs when verbal expression of the message mathces the sender's nonverbal body language
  4. familial
    occuring in or affecting members of a family more than would be expected by chance
  5. present illness
    the chief compaint, written in chronologic sequence with dates of onset
  6. psychosocial
    peraining to a combination of psychological and social factors
  7. rapport
    a relationship of harmony and accord between the patient and the healthcare professional
  8. 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)
  9. 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
  10. holistic care
    . includes assessing the patient's health status with physcial, cognitive, psychosocial and behavioral data

    . the whole patient
  11. PMH
    • past medical history
    • . previous health
    • . usual childhood diseases, allergies, surgeries , accidents and immunization record
  12. FH
    family history
  13. SH
    • social history
    • . lifestyle
    • . occupation
    • . hobbies
    • . education
  14. ROS
    • review of systems
    • . help detect conditions other than those covered under the present illness
  15. empathy
    . is the key to creating a caring therapeutic environment

    . requires those in healthcare services to examine their own values, beliefs , and actions
  16. listening must be an active process in a therapeutic relationship such as
    • . restatement
    • . reflection
    • . clarification
  17. nonverbal communication
    . approximately 90% of patient interactions occur through nonverbal language

    . successful patient interaction has congruent verbal and nonverbal messages.
  18. preparing the appropriate environment
    • . ensure privacy
    • . refuse interruptions
    • . prepare comfortable surroundings
    • . take judicious notes
  19. 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
  20. 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?
  21. interviewing the patient contract between the medical assistant and patient three parts
    • . initiation or introduction
    • . the body
    • . the closing
  22. interview barriers
    • . providing unwarranted assurance
    • . giving advice
    • . using medical terminolgy
    • . asking leading questions
    • . talking too much
    • . using defense mechanisms
  23. 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
  24. s
    • . subjcetive data
    • . chief complaint in patients words
  25. o
    • . objective data
    • . anything that is observed or measurable
  26. a
    • . assessement
    • . physician's tentative diagnosis
  27. p
    • . plan of care
    • . physician documents how health problem will be managed
  28. e
    • . evaluation
    • . assessment of treatment outcome
  29. new diagnosis is called
    differentiated diagnosis
  30. database
    the record of patient name, address, date of birth, insurance information, personal data , history, physical exam, and initial laboratory findings
  31. progress notes should include
    • . the purpose of the visits written as chief complaint
    • . vital signs
    • . pain report 1 to 10
  32. denial
    the patient completely rejects the information

    .  I couldn't possible have breast cancer. you must mistaken
  33. 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
  34. 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
  35. projection
    the patient accuses someone else of having the feeling that she has

    . you don't have to lose your temper about this
  36. 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
  37. 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
  38. 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
  39. sublimation
    the patient redirects her negative feelings into a socially productive activity

    . becoming a member of local support group
  40. cardinal symptoms
    symptoms of the greatest significanace in identifying a disease

    • . crushing chest pain
    • . difficulty breathing
  41. 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
  42. EMR
    • . electronic medical record
    • . use passwords
  43. patient education
    the perfect time to initiate patient education is during the initial patient interview
  44. 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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chapter 28
chapter 28