100%
"Why are we seeing you today". must hear them say why - ANSWERWhat must be
asked at every visit
a physical or physicologial dependacy on a substance - ANSWERaddiction
what a patient is being seen for - ANSWERchief complaint
the basis for all treatment rendered; information for research, reportable diseases,
insurance claims - ANSWERWhat is the medical health history for?
1996 - ANSWERWhen was HIPAA created
2003 - ANSWERWhen was HIPAA enforced
cthoughts, feelings perceptions of the patient, goes with chief complaint -
ANSWERsubjective data
Abnormally deep or rapid respiration - ANSWERhyperpnea
asking questions to provide an increased understanding - ANSWERclarification
restaing in your own words what a person is saying - ANSWERmirroring
information about the patient's condition that is readily apparent or measurable -
ANSWERobjective data
when a thought, idea, or opinion is formed as a result of deeper thought -
ANSWERreflection
repeating what a patient says in your own words back to the patient -
ANSWERrestatement
C-client's words exactly
C-clarity
C-completeness
C-conciseness
C-chronological order
C-confidentiality - ANSWERWhen documenting patient information, what are the 6
C's?