NURS 612 Exam 1 Key Points to Review
**Please note that this is an optional tool to use in preparation for Exam 1. It may
or may not contain all the content on Exam 1. **
Health History, SOAP, Patient-Centered Care, Telehealth
and Culture
Key Point to Review Student Notes
What are the concepts in developing a
relationship with the patient?
What are some effective
communication strategies when
obtaining a health history?
What is a patient-centered question?
Give examples.
What are some potential barriers of
patient and provider communication?
What are the structure and the Identifying info (name, dob, health
components of a patient history? What record number)
kind of patient information is obtained Problems, Allergies, Medications, and
in each section? Immunization list
General Patient Information
Source and Reliability of Info
Chief Concern
History of present illness: OLDCARTS
PMH (hospitalizations, surgeries,
childhood illnesses, major adult
illnesses, serious injuries,
immunizations, medications, allergies,
transfusions, mental health, recent lab
tests
Family History (3 generations of major
health or genetic disorders like HTN,
cancer, respiratory, kidney disease,
strokes, or thyroid disorders, asthma or
other allergic manifestations, blood
dyscrasias, psychiatric illness,
tuberculosis, rhumatologic diseases,
DM, hepatitis, etc. *include all ages and
health status)
Personal and social history (cultural
background and practices, birthplace,
religious preferences, hobbies and
interests, sources of stress, home
, environment, school and work
environment, current health habits and
eating habits, exposure to toxins,
military service record, sexual activity,
concerns about cost of care and
healthcare coverage)
What is the difference between Subjective data: the information,
objective and subjective data? What including the absence or presence of
components of the health history are pertinent symptoms, that the patient
objective and what components are tells you
subjective? -info that the patient offers about their
condition; describes the patient’s
concerns or unexpected findings by
their quality or character
Objective data: your direct
observations from what you see, hear,
smell, and touch and from diagnostic
test results
-relate physical findings to the
processes of inspection, palpation,
auscultation, and percussion, making
clear the process of detection so
confusion does not occur
How do you approach sensitive issues
when interviewing a patient?
What does it mean to be culturally Awareness of and responsiveness to
aware and culturally competent when patient’s background and cultural
caring for patients with diverse experiences including their preferences,
values, language, and traditions, among
backgrounds? other things.
Social context- inquire about stressors and
support networks, sense of life control, and
literacy
-providers need to be flexible and creative
-Cultural competence: understands the
meaning of culture, is knowledgeable about
different cultures, appreciates diversity, is
aware of health disparities and discrimination
affecting minority groups, effectively uses
interpreter services when needed
-Cultural awareness: the deliberate self-
examination and in-depth exploration of
one’s biases, stereotypes, prejudices,
assumptions, and ‘isms’ that one holds about
individuals and groups who are different from
them
Provide some examples of questions to What are your pronouns?
explore the patient’s culture. Health Beliefs and Practices:
-How does the patient define health and
**Please note that this is an optional tool to use in preparation for Exam 1. It may
or may not contain all the content on Exam 1. **
Health History, SOAP, Patient-Centered Care, Telehealth
and Culture
Key Point to Review Student Notes
What are the concepts in developing a
relationship with the patient?
What are some effective
communication strategies when
obtaining a health history?
What is a patient-centered question?
Give examples.
What are some potential barriers of
patient and provider communication?
What are the structure and the Identifying info (name, dob, health
components of a patient history? What record number)
kind of patient information is obtained Problems, Allergies, Medications, and
in each section? Immunization list
General Patient Information
Source and Reliability of Info
Chief Concern
History of present illness: OLDCARTS
PMH (hospitalizations, surgeries,
childhood illnesses, major adult
illnesses, serious injuries,
immunizations, medications, allergies,
transfusions, mental health, recent lab
tests
Family History (3 generations of major
health or genetic disorders like HTN,
cancer, respiratory, kidney disease,
strokes, or thyroid disorders, asthma or
other allergic manifestations, blood
dyscrasias, psychiatric illness,
tuberculosis, rhumatologic diseases,
DM, hepatitis, etc. *include all ages and
health status)
Personal and social history (cultural
background and practices, birthplace,
religious preferences, hobbies and
interests, sources of stress, home
, environment, school and work
environment, current health habits and
eating habits, exposure to toxins,
military service record, sexual activity,
concerns about cost of care and
healthcare coverage)
What is the difference between Subjective data: the information,
objective and subjective data? What including the absence or presence of
components of the health history are pertinent symptoms, that the patient
objective and what components are tells you
subjective? -info that the patient offers about their
condition; describes the patient’s
concerns or unexpected findings by
their quality or character
Objective data: your direct
observations from what you see, hear,
smell, and touch and from diagnostic
test results
-relate physical findings to the
processes of inspection, palpation,
auscultation, and percussion, making
clear the process of detection so
confusion does not occur
How do you approach sensitive issues
when interviewing a patient?
What does it mean to be culturally Awareness of and responsiveness to
aware and culturally competent when patient’s background and cultural
caring for patients with diverse experiences including their preferences,
values, language, and traditions, among
backgrounds? other things.
Social context- inquire about stressors and
support networks, sense of life control, and
literacy
-providers need to be flexible and creative
-Cultural competence: understands the
meaning of culture, is knowledgeable about
different cultures, appreciates diversity, is
aware of health disparities and discrimination
affecting minority groups, effectively uses
interpreter services when needed
-Cultural awareness: the deliberate self-
examination and in-depth exploration of
one’s biases, stereotypes, prejudices,
assumptions, and ‘isms’ that one holds about
individuals and groups who are different from
them
Provide some examples of questions to What are your pronouns?
explore the patient’s culture. Health Beliefs and Practices:
-How does the patient define health and
