68W LIMITED PRIMARY CARE
QUESTIONS AND ANSWERS (GRADED
A+)
DD Form 689 - ANSWER-Individual sick call slip that initiates the sick call process
Used for patient who requests or receives medical/dental evaluation or treatment at an
Army Medical Treatment Facility (MTF)
used as a means of communication between medical personnel and the patient's
commander
SF 600 - ANSWER-Chronological Record of Medical Care
form used to document the chronological record of the patient's treatment
Should include:
- Date and time of visit
- Medical Treatment Facility
- Signature of person making entry
Correction procedures for an entry error - ANSWER-Draw a single line through the
information, write "Error," and your initials
If you have finished the documentation and decide later information needs to be
changed:
- add correct information
- reason for change
- date and initial
- Do not skip lines or leave any spaces above signature
HIPAA - ANSWER-Health Insurance Portability and Accountability Act
a federal law protecting the privacy of patient-specific health care information
Access to patient's medical information may be given too... - ANSWER-- the patient
- patient care personnel
- medical researcher
- medical educators
,Exceptions for those that can access a patient's medical information are... - ANSWER--
if access is court ordered by law
- if access if needed for hospital accreditation
- if access is authorized by the patient via a written document
Disclosure of medical information is handled by... - ANSWER-the PA or the patient
administrator (PAD)
History Taking Techniques - ANSWER-1) Observation - begins when patient walks
through the door
2) Listening - will help you find out the problem
3) Open-ended questions - helps you get more complete and accurate information
4) Provider obstacles - keep a good attitude and assume every patient has a legitimate
complaint
5) Patient obstacles - patient's w/o medical experience will very often request specific
diagnostic studies, therefore, we must gain their trust
6) Obtain a thorough history
7) Maintain an index of suspicion
8) Consider the mechanism of injury
Triage - ANSWER-Triage is about looking for signs and symptoms that could lead to
serious illness or even death
You may decrease the likelihood of overlooking these conditions by maintaining an
index of suspicion based on the presenting symptoms and by obtaining accurate vital
signs on each and every patient
Techniques for Identifying Critically Ill Patients - ANSWER-- Obtain the chief complaint
- Identify patients with signs and symptoms that have increased potential for
complications
- promptly obtain vital signs
- perform a physical exam and report findings to medical provider
Initiating the Sick Call Process - ANSWER-1) Patient will obtain a DD Form 689., an
individual sick slip, which will ensure accountability of the soldier is maintained both at
the MTF and with patient's unit
2) a combat medic will be assigned to sign in all patients in a daily disposition log
, 3) the combat medic will retrieve the patient's medical record and initiate an entry on a
SF 600, or the Chronological Record of Medical Care
4) Combat medic will take the patient's vital signs and initiate an entry on SF 600 in a
SOAP format by asking for the patient's HPI
5) Physical examination will be performed by the Medical Officer
Types of microorganisms - ANSWER-Algae - resemble plant cells and are found in
sunlit water
Fungi - includes yeasts and molds (tinea pedis or athlete's foot)
Protozoa - single-celled microorganisms (trichomonas vaginalis)
Bacteria - single-celled organisms without a nucleus. Spore forming bacteria are the
most difficult to control and destroy because the spores protect the bacteria from
extreme conditions
Viruses - must use the host's ability to make protein and energy. Immunization is the
most effective means for preventing viral infections (ex: polio)
Communicable diseases - ANSWER-diseases that can spread from one person to
another
Contagious diseases - ANSWER-diseases that are easily and rapidly spread from one
person to another
Subjective Information - ANSWER-Subjective information is information that the patient
tells you. It is what the patient reports he feels or understands as the problem. It is
information that you cannot necessarily find in an examination.
- age, sex, race and first day of last menstrual period (FDLMP)
- chief complaints
- HPI - contains all of the relevant information to the patient's chief complaint
- past medical/surgical/social history
- last oral intake
- events leading up to illness or injury
QUESTIONS AND ANSWERS (GRADED
A+)
DD Form 689 - ANSWER-Individual sick call slip that initiates the sick call process
Used for patient who requests or receives medical/dental evaluation or treatment at an
Army Medical Treatment Facility (MTF)
used as a means of communication between medical personnel and the patient's
commander
SF 600 - ANSWER-Chronological Record of Medical Care
form used to document the chronological record of the patient's treatment
Should include:
- Date and time of visit
- Medical Treatment Facility
- Signature of person making entry
Correction procedures for an entry error - ANSWER-Draw a single line through the
information, write "Error," and your initials
If you have finished the documentation and decide later information needs to be
changed:
- add correct information
- reason for change
- date and initial
- Do not skip lines or leave any spaces above signature
HIPAA - ANSWER-Health Insurance Portability and Accountability Act
a federal law protecting the privacy of patient-specific health care information
Access to patient's medical information may be given too... - ANSWER-- the patient
- patient care personnel
- medical researcher
- medical educators
,Exceptions for those that can access a patient's medical information are... - ANSWER--
if access is court ordered by law
- if access if needed for hospital accreditation
- if access is authorized by the patient via a written document
Disclosure of medical information is handled by... - ANSWER-the PA or the patient
administrator (PAD)
History Taking Techniques - ANSWER-1) Observation - begins when patient walks
through the door
2) Listening - will help you find out the problem
3) Open-ended questions - helps you get more complete and accurate information
4) Provider obstacles - keep a good attitude and assume every patient has a legitimate
complaint
5) Patient obstacles - patient's w/o medical experience will very often request specific
diagnostic studies, therefore, we must gain their trust
6) Obtain a thorough history
7) Maintain an index of suspicion
8) Consider the mechanism of injury
Triage - ANSWER-Triage is about looking for signs and symptoms that could lead to
serious illness or even death
You may decrease the likelihood of overlooking these conditions by maintaining an
index of suspicion based on the presenting symptoms and by obtaining accurate vital
signs on each and every patient
Techniques for Identifying Critically Ill Patients - ANSWER-- Obtain the chief complaint
- Identify patients with signs and symptoms that have increased potential for
complications
- promptly obtain vital signs
- perform a physical exam and report findings to medical provider
Initiating the Sick Call Process - ANSWER-1) Patient will obtain a DD Form 689., an
individual sick slip, which will ensure accountability of the soldier is maintained both at
the MTF and with patient's unit
2) a combat medic will be assigned to sign in all patients in a daily disposition log
, 3) the combat medic will retrieve the patient's medical record and initiate an entry on a
SF 600, or the Chronological Record of Medical Care
4) Combat medic will take the patient's vital signs and initiate an entry on SF 600 in a
SOAP format by asking for the patient's HPI
5) Physical examination will be performed by the Medical Officer
Types of microorganisms - ANSWER-Algae - resemble plant cells and are found in
sunlit water
Fungi - includes yeasts and molds (tinea pedis or athlete's foot)
Protozoa - single-celled microorganisms (trichomonas vaginalis)
Bacteria - single-celled organisms without a nucleus. Spore forming bacteria are the
most difficult to control and destroy because the spores protect the bacteria from
extreme conditions
Viruses - must use the host's ability to make protein and energy. Immunization is the
most effective means for preventing viral infections (ex: polio)
Communicable diseases - ANSWER-diseases that can spread from one person to
another
Contagious diseases - ANSWER-diseases that are easily and rapidly spread from one
person to another
Subjective Information - ANSWER-Subjective information is information that the patient
tells you. It is what the patient reports he feels or understands as the problem. It is
information that you cannot necessarily find in an examination.
- age, sex, race and first day of last menstrual period (FDLMP)
- chief complaints
- HPI - contains all of the relevant information to the patient's chief complaint
- past medical/surgical/social history
- last oral intake
- events leading up to illness or injury
