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Screening
- The process of obtaining info from patient to determine medical condition (Chief Complaint C.C.)
- Has replaced word Triage
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Triage
- French word for sort
- Developed by the military
- Used to help prioritize by injury
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Triage Order
- 1. Breathing is most important, then most severe injured (chest pain, severe bleeding, poisoning, etc)
- 2. Next less severe (major / multi fractures, 2nd burns, back injury, severe eye injury)
- 3. All others saved for last
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Subjective
- Information received from patient they feel, not measureable
- (Pain, dizziness, itchy)
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Objective
- Measureable by any other person
- (Swelling, bruising, rash, vital signs)
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SOAP
- Used by Dr's to obtain patient info during visit
- Subjective, Objective (MA does)
- Assessment, Plan (Dr does)
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11 Factors Influencing Screening
- Privacy, Biases, Relaxed Atmosphere
- Non-verbals, Understands, Patient Talking
- Listening Skills, Patient non-verbals
- Open ?'s, Focus Interview, Summary
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History of Present Illness (HPI)
- Self treatment, effects of treatment
- Other symptoms of CC
- What helps / aggrivates
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LASTSAQ
- Location
- Association
- Setting
- Timing
- Severity
- Alleviation / Aggrivation
- Quality
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Medication
- All current medications
- All over the counter drugs
- All suppliments
- All vitimins
- All home remedies
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NKDA
No Known Drug Allergies
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Genogram
- A diagram of family and their diseases
- Both sides
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Over The Counter
- OTC
- Meds, vitimins, suppliments
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Review of Body Systems
- ROS
- Helps patient remember previous illness / symptoms
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UCHD
Usual Childhood Disease
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