Advanced Health Assessment - Quiz 2 Study Guide.doc

Advanced Health Assessment - Quiz 2 Study GAdvanced Health Assessment – Quiz 2 Study Guide Focus on your studies on the readings from Bates’ text Chs. 1, 2, 3, 4, 5, 6, and 7 and the corresponding PowerPoint (PPT) slides/audio lectures.  Differentiate comprehensive versus a focused (or episodic) history and physical examination  Comprehensive (Complete) Assessment  Appropriate for new patients in the office or hospital  Always should be done on all new patients never seen before  Provides fundamental and personalized knowledge about the patient  Strengthens the clinician-patient relationship  Helps identify or rule out physical causes related to patient concerns  Provides a baseline for future assessments  Creates a platform for health promotion through education and counselling  Develops proficiency in the essential skills of physical examination  Requires a greater length of time  Includes all of the patient’s past medical history, family history, personal and social history, medications, allergies, and complete review of all systems (ROS)  Focused (Episodic, Problem-oriented, SOAP)  Appropriate for established patients, especially during routine or urgent care visits  Addresses focused concerns or symptoms  Assesses symptoms restricted to a specific body system  Addresses only specific body systems as it relates to the reported concerns/ symptoms  Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible  Elements of the SOAP note  Subjective vs. Objective data  Subjective Data  What the person tells you  The history from chief complaint through review of systems  Reported by the patient  Patient perspective  Patient’s feelings, beliefs, desires, etc.  Information that cannot be measured  Makes up your health history portion of clinical encounter  Objective Data  What you detect during examination  All physical examination findings  What you see, hear, feel, touch, smell  Labs and diagnostic tests  Information that can be directly observed and measured by the clinician  Components of a health history AND what type of information is collected in each area  Initial Information  Date and time of evaluation of the patient  Identifying Data  Age and gender  Source and Reliability  Who is providing you the information?  Patient? Family? Friend?  Is the patient reliable?  Chief complaint (C/C) Harryson  Reason for the patient visit  Should be documented in the patient’s own words (or that of the person reporting if not the patient)  Should be documented in one sentence  Examples:  “I have chest pain”  “I am here for an annual wellness visit”  “Mom was acting confused”  In a case where someone other than patient is reporting  A poor example is “I am here for a follow up”  Better is “I’m here for a follow-up evaluation of my sprained ankle”  History of Present Illness (HPI)  Expansion of the chief complaint, as if you are telling a story  Sequential (chronological description) of the patient’s subjective report of experiences/ symptoms related to the chief complaint or reason for clinical encounter  Should include a relative description of the patient’s complaints and issues, baseline health, a narrative of events leading up to the visit  Includes pertinent positives and pertinent negatives  Pertinent positives – patient reports or affirms a finding (what the patient has)  Examples: weight loss within 3 weeks or cough with mucous production  Pertinent negatives – patient denies a finding (patient does not have)  No nausea, vomiting, diarrhea, constipation, denies fever  Should always include pertinent positives and negatives in your HPI and ROS  Attributes of each system reported should be fully described  Organize questions about reported symptoms using OLD CARTS and Box 3-4 in text  OLD CARTS is used to pursue the attributes of patient’s symptoms and is documented as part of the HPI  With example: chest pain  O – onset  When did the chest pain start? (Document the actual date if possible)  Ask what the patient was doing (what caused it?)  L – location  Can you tell me exactly where the pain in?  Ask the patient to point to it  D – duration  How long did/does the pain last?  Ask if they have any more occurrences of the chest pain and describe each instance  C – character  Describe what the pain feels like, exactly how they feel  Provide descriptor words such as sharp, burning, stabbing, pressure, etc.  A – aggravating / alleviating factors  Does anything make the pain feel worse or better