NURS 5220: Module 1 WITH ALL ANSWERS
CORRECTLY DONE !!!
1. SOAP note:ANS SOAP note is both a process and a documentation format
2. The Partnership with the Patient ANS: Getting to know your
client: Culture
Physical characteristics Influence on health and illness
Beliefs and behaviors Family relationships Preparing to be an effective health care
provider
3. The History and Interviewing process ANS: The history and physical exam
begin the diagnostic and treatment process
The techniques you will learn are orderly but not rigid
To prevent misinterpretations and misperceptions, you must make every effort to
view the patient's perspective.
4. GOALS: ANS Discover information leading to diagnosis and management
Provide information about diagnosis
Negotiate and share health care management
Counsel about disease prevention
5. Autonomy: ANS Patient's self-determination
6. Beneficence: ANS Do good for the patient
7. Nonmaleficence: ANS Do no harm to the patient
8. Utilitarianism: ANS Appropriate use of resources for the greater good
9. Fairness and Justice: ANS Equitable treatment of all
10. Deontological imperatives: ANS Care delivered according to traditions and
,in cul- tural contexts
11. Factors that Enhance Communication: ANS Establishing a positive patient
rela- tionship depends on communication built on: Courtesy Comfort Connection
Confir- mation Confidentiality
Be Professional:
Attire & Response
12. Enhancing Patient Responses: ANS Establish rapport and trust-Seek
connection Open Ended Question-Allows patient discretion about the extent of
an answer Direct Question-Seeks specific information
,Leading Question
-May limit the information provided to what the patient thinks you want to know
13. If the patient does not understand what you are asking, remember to::
ANS Fa- cilitate: Encourage your patient to say more
Reflect: Repeat what you have heard.
Clarify: Ask "What do you mean?"
Empathize: Show understanding and acceptance.
Confront: Address disturbing patient behavior.
Interpret: Repeat what you have heard to confirm the patient's meaning.
14. Communication TensionsLimit barriers: ANS curiosity
about you anxiety
silence
depression
crying
physical intimacy
emotional intimacy
anger
avoidance
financial considerations
15. Setting for the Interview: ANS
comfort removal of physical barriers
good lighting
privacy
quiet
unobtrusive access to clock
16. Taking the history usually begins...: ANS your relationship with the patient
17. Structure of the History: ANS Identifiers: name, date, time, age, gender,
race, occupation, and referral source
• Chief concern/complaint (CC)
• History of present illness (HPI)
• Past medical history (PMH)
• Family history (FH)
• Personal and social history (PH/ SH)
• Review of systems (ROS)
, 18. Basic Rules for Building the History: • Introduce yourself
• Address patient properly
• Be courteous
• Make eye contact
• Do not overtire patient
• Do not be judgmental
• Be flexible
Avoid medical jargon
• Take notes sparingly
• Avoid leading questions
• Start with general concerns, then move to specific descriptions.
• Clarify responses with where, when, what, how, and why questions.
• Verify and summarize what you have heard
19. Building the History: • Identify what the patient defines as problems.
• Establish patient's reliability.
• Consider intentional or unintentional suppression or underreporting of information.
• Evaluate patient's words and behaviors.
• Adapt to the modifications that age, pregnancy, and physical and emotional
handicaps mandate
20. Approaching Sensitive Issues: • Ensure privacy.
• Be direct and firm.
• Do not apologize for broaching the issue.
• Do not preach.
• Use language that is understandable.
• Do not push too hard.
21. Sensitive Issues: • Alcohol and drug use
• Domestic violence
• Spirituality
• Sexuality
22. CAGE Questionnaire: - Cutting down
- Annoyance by criticism
- Guilty feeling
- Eye openers
23. TACE Questionnaire: T-How many drinks does it Take to make you feel high?
A-Have people Annoyed you by criticizing your drinking?
C-Have you felt you ought to Cut down on your drinking?
CORRECTLY DONE !!!
1. SOAP note:ANS SOAP note is both a process and a documentation format
2. The Partnership with the Patient ANS: Getting to know your
client: Culture
Physical characteristics Influence on health and illness
Beliefs and behaviors Family relationships Preparing to be an effective health care
provider
3. The History and Interviewing process ANS: The history and physical exam
begin the diagnostic and treatment process
The techniques you will learn are orderly but not rigid
To prevent misinterpretations and misperceptions, you must make every effort to
view the patient's perspective.
4. GOALS: ANS Discover information leading to diagnosis and management
Provide information about diagnosis
Negotiate and share health care management
Counsel about disease prevention
5. Autonomy: ANS Patient's self-determination
6. Beneficence: ANS Do good for the patient
7. Nonmaleficence: ANS Do no harm to the patient
8. Utilitarianism: ANS Appropriate use of resources for the greater good
9. Fairness and Justice: ANS Equitable treatment of all
10. Deontological imperatives: ANS Care delivered according to traditions and
,in cul- tural contexts
11. Factors that Enhance Communication: ANS Establishing a positive patient
rela- tionship depends on communication built on: Courtesy Comfort Connection
Confir- mation Confidentiality
Be Professional:
Attire & Response
12. Enhancing Patient Responses: ANS Establish rapport and trust-Seek
connection Open Ended Question-Allows patient discretion about the extent of
an answer Direct Question-Seeks specific information
,Leading Question
-May limit the information provided to what the patient thinks you want to know
13. If the patient does not understand what you are asking, remember to::
ANS Fa- cilitate: Encourage your patient to say more
Reflect: Repeat what you have heard.
Clarify: Ask "What do you mean?"
Empathize: Show understanding and acceptance.
Confront: Address disturbing patient behavior.
Interpret: Repeat what you have heard to confirm the patient's meaning.
14. Communication TensionsLimit barriers: ANS curiosity
about you anxiety
silence
depression
crying
physical intimacy
emotional intimacy
anger
avoidance
financial considerations
15. Setting for the Interview: ANS
comfort removal of physical barriers
good lighting
privacy
quiet
unobtrusive access to clock
16. Taking the history usually begins...: ANS your relationship with the patient
17. Structure of the History: ANS Identifiers: name, date, time, age, gender,
race, occupation, and referral source
• Chief concern/complaint (CC)
• History of present illness (HPI)
• Past medical history (PMH)
• Family history (FH)
• Personal and social history (PH/ SH)
• Review of systems (ROS)
, 18. Basic Rules for Building the History: • Introduce yourself
• Address patient properly
• Be courteous
• Make eye contact
• Do not overtire patient
• Do not be judgmental
• Be flexible
Avoid medical jargon
• Take notes sparingly
• Avoid leading questions
• Start with general concerns, then move to specific descriptions.
• Clarify responses with where, when, what, how, and why questions.
• Verify and summarize what you have heard
19. Building the History: • Identify what the patient defines as problems.
• Establish patient's reliability.
• Consider intentional or unintentional suppression or underreporting of information.
• Evaluate patient's words and behaviors.
• Adapt to the modifications that age, pregnancy, and physical and emotional
handicaps mandate
20. Approaching Sensitive Issues: • Ensure privacy.
• Be direct and firm.
• Do not apologize for broaching the issue.
• Do not preach.
• Use language that is understandable.
• Do not push too hard.
21. Sensitive Issues: • Alcohol and drug use
• Domestic violence
• Spirituality
• Sexuality
22. CAGE Questionnaire: - Cutting down
- Annoyance by criticism
- Guilty feeling
- Eye openers
23. TACE Questionnaire: T-How many drinks does it Take to make you feel high?
A-Have people Annoyed you by criticizing your drinking?
C-Have you felt you ought to Cut down on your drinking?
