Chief Complaint Assessment
A patient describes chest pressure radiating to the left arm with sweating, commonly associated with myocardial infarction.
chest pain
Term used for Body Measurements
Mensuration
A health history form can be filled out how?
Through an EMR system or in-person
The reason a patient is visiting the office, documented in their own words
Chief complaint.
A patient presenting sudden facial droop, arm weakness, and slurred speech is experiencing signs of?
Stroke
(O), (R), (TA), (AX), (AU)
What are the abbreviations for Oral, Rectal, Temporal, Axillary & Aural Tympanic Temperatures?
Where in a health history form would heavy lifting and caffeine be documented?
Occupational/ Social history
HIPAA stands for
Health Insurance Portability and Accountability Act
A patient is showing signs of difficulty breathing. This symptom is commonly associated in asthma and COPD
Shortness of Breath (Dyspnea)
The least accurate location for observing T
Axillary (Ax)
SAMPLE
Signs and symptoms
Allergies
Medications
Past medical history
Last oral intake
Events leading up
The difference between subjective and objective in a SOAP note
Subjective- personal feelings, opinions.
Objective- Facts and evidence.
A patient presents with sudden pain that radiates to the groin and may have blood in the urine.
Kidney Stones (Nephrolithiasis)
5 VITALS?
TPR,BP, O2
What is the purpose of health history?
It is a basis for all treatment and a guide for future treatment.
3 things to do when there is an error in a paper chart
Cross out, date and initial the error.
A patient with abdominal pain, nausea, and vomiting who also has pain in the lower right side of the abdomen may be experiencing this condition and should be evaluated quickly.
appendicitis
BMI formula
(Pt wt. x 703) / Pt height in " / Pt height in " round to nearest whole no.
Clinical Diagnosis
Information from the patient Px, health history, ROS, and lab results for initial treatment.
Medicare part A covers
Hospital services