Consultation verbiage instance - ANS-"The pt is visible in consultation at the request of Dr.
Welby for evaluation of abdominal pain", "Dr. Ben Casey has requested consultation of Jane
Doe for pre-op clearance".
** Must continually consist of the phrase CONSULTATION
Foundation of the HPI is the PQRST format; what does it stand for? - ANS-Provocative
Quality or Quantity
Region/Radiation
Severity
Timing
How regularly should patients get a preventative examination? - ANS-Routine fitness
examination accomplished every 1-three years earlier than age 50 and each year thereafter
In PQRST, what are the components of P? - ANS-1. What causes the symptom
2. What makes it worse or higher?
3. What do you do for it? Meds/rest?
Four. Look for triggers, relievers, aggravators
In PQRST, what are the additives of Q? - ANS-1. How does it experience, look, sound, or smell?
2. How mucharyou experiencing now?
3. Does it intervene with ADLs?
4. Is it worse, better, or one-of-a-kind than the ultimate time?
In PQRST, what are the components of R? - ANS-Where is it placed?
Does it travel everywhere else to your frame?
In PQRST, what are the additives of S? - ANS-1. On a scale of 1 - 10, how horrific is it?
2. At its worse do you have to take a seat down, lie down, or sluggish down?
Three. Is it getting better, worse, or the equal?
In PQRST, what are the additives of T? - ANS-1. When did it begin? Date/time?
2. Type of onset - how did it start? Suddenly or regularly
three. Frequency - how often does it occur? When does it occur? What time of day? Does it
wake you up? Does it manifest after/before meals? Seasonal?
4. Duration - how long does it closing?
Provocative Components - ANS-What reasons the symptom
What makes it worse or higher?
What do you do for it? Meds/rest?
Looking for triggers, relievers, aggravators
Quality or Quantity Components - ANS-How does it experience, appearance, sound, or scent?
How a good deal are you experiencing now?
Does it interfere with ADLs?
Is it worse, better, or one of a kind than the ultimate time?
Region/Radiation - ANS-Where is it located?
, Does it tour everywhere else to your frame?
Severity - ANS-On a scale of 1 - 10, how horrific is it?
At its worse do you need to take a seat down, lie down, or sluggish down?
Is it getting higher, worse, or the equal?
Timing - ANS-When did it begin? Date/time?
Type of onset - how did it start? Suddenly or gradually
Frequency - how frequently does it occur? When does it arise? What time of day? Does it wake
you up? Does it show up after/earlier than meals? Seasonal?
Duration - how long does it final?
What are the components of a CC? - ANS-The motive for seeking care IN QUOTES
What are the additives of a COMPLETE health evaluation? - ANS-CC, HPI, PMH, FH, Social
Hx, ROS, Genogram
What are the components of a FH? - ANS-CAD, cholesterol
DM
HTN, stroke
CA
TB
Asthma
Bleeding, anemia
Alcoholism
Weight, intellectual health
What are the additives of a FOCUSED fitness evaluation? - ANS-CC, HPI, PMH, FH/SH that
relates to complaint, specific system ROS
What are the additives of a HPI? - ANS-History of gift infection
A certain description of the number one hassle the usage of symptom analysis. Use PQRST
format
What are the additives of a PMH? - ANS-Childhood/person illness
Surgeries with dates
Immunizations
Pediatric, adolescent, and person
Serious harm/trauma - transfusions
Medications
Prescription
OTC
Allergies and reaction
Screening tests
Psychiatric/intellectual health problems
What are the additives of a PMH? (past med hx) - ANS-Childhood/grownup infection
Surgeries with dates
Immunizations
Pediatric, adolescent, and grownup
Serious injury/trauma - transfusions
Medications