Health Assessment Midterm Study Guide

Building A Complete Health History (Week 1) Chapters 1 & 26 •Communication techniques used to obtain a patient’s health history Chapter 1 -Open ended questions: gives the patient discretion about the extent of the answer -Direct question: seeks specific information -Leading question: most risky, may limit information -Courtesy, comfort, connection, confirmation -CAGE questionnaire screening: designed to help diagnose alcoholism -CRAFT screening: ETOH and substance abuse in adolescents (Car, Relax, Forgot, Friends, Trouble) -TACE screening: drinks does it take to feel high, people Annoyed you about your drinking, Cut back drinking, Eye opener drink in the AM -Partner violence screen (PVS): hit kicked or punched, feel unsafe… -Domestic Violence (HITS): Hurt you physical, Insult you, Threaten you, Scream at you? -Spirituality (FICA): Faith, Importance, Community, Address -Types of histories: Complete, inventory (touches up on major points), Problem (focused, acute life-threatening problem), Interim (designed to chronicle events that have occurred since last meeting) •Recording and documenting patient information Chapter 26 -Write out abbreviations Copy and paste or carry forward (CPCF) -International Classification of Disease (ICD): diagnostic coding system that classifies diseases and injuries and u used to track mortality and morbidity -Geriatric screening tool: Katz Index consists of six items (bathing, dressing, toileting, transferring, continence and feeding