Allergies Correct Answers -medication allergies & type of
reaction
-latex allergy
-food allergies
Communication skills checklist (random stuff) Correct Answers
during interview:
-ID chief complaint early in the interview
-ask "anything else" to check for other concerns
-summarize
at the end:
-ask if patient has any questions
-give initial impression of plan
Family history Correct Answers -genogram reviewed with
patient
-assessed for high risk conditions/diseases
Health behaviors - the rest: Correct Answers -*nutrition:*
typical day = fats, sugars, salt, & iron; food groups; caffeine use
-*exercise:* type, duration/intensity, frequency
-*sex:* satisfaction, orientation; STD risk = new & multiple
partners, use of protection, contraception status
-*injury prevention:* safety belt use and smoke alarms
-*living situation:* current living conditions, household
members, neighborhood violence
-*sleep:* amount & quality
-*hobbies:* leisure/rest/relaxation/sports
-*dental health:* visit dentist periodically; floss & brush daily
, -*immunizations:* last tetanus, flu, varicella, pneumococcal (if
smoker)
-*screening tests:* when's the last time you got blood drawn for
testing (such as cholesterol); last colonoscopy; last mammogram
and pap for female
-NESIS
Health behaviors - tobacco/alcohol/drugs: Correct Answers -
tobacco: age onset/duration
-tobacco: type & packs per day
-tobacco: assess readiness to quit
-tobacco: prior quit attempts
-alcohol use: yes/no & type of alcohol
-alcohol use: 5(M)/4(F) or more drinks/day in past year
-alcohol/drug use and driving, etc.
-illicit drug use
HPI Correct Answers -ID the patient ("This patient is a 64 yo
white female with multiple medical problems, most notably...")
-develop the patient's story w/ only important and relevant
history to what will be discussed in the assessment and plan
Identifying data Correct Answers -name
-age
-gender
-race
-source of information (and if it's reliable)
Medications Correct Answers -prescription meds
-OTC meds
-herbs & supplements