Defense Mechanisms
Patient reverts to an old, usually immature behavior. Ex: pt may storm out of office saying "I can't schedule any treatments until I discuss this with my mother"
Regression
This is the report as to why the patient is being seen today
Chief complaint or present illness
Pt could get hostile toward MA or physician and comments could include "Why did this happen to me? I'm a good person, why did I get this disease?"
Anger
Anything that is observed or measurable, including vital signs, exact location of an injury, difficulty walking, and so on.
O- objective data
This area looks at how the patients emotional reaction to the diagnosis affects the response to patient education and coaching efforts. Are they in shock and denial? angry or depressed?
Psychological
Patient accuses someone else of having the feeling they have. Ex: if the patient is angry about the diagnosis they may say "you don't have to lose your temper about this" even though the MA remains completely professional
Projection
Details about patients parents and siblings and their health. If they are deceased the age and cause of death
Family history
Patient grieves the loss of health. Patient dosen't want to have to deal with disease, just wants it to go away
Depression
This is the provider's documentation of how the health problem will be managed, including diagnostic studies, treatments, and patient education
P- plan of care
This area addresses if the patient is able to understand the complexities of the disease and treatment recommendations
Intellectual
Patient expresses feelings as opposite of what they really feel. Ex: if they are mad about the MA insisting to schedule a treatment they may say "I appreciate your help, but I can't come to the hospital that day"
Reaction formation
These questions provide a guide to the patient's general health and help detect conditions other than those covered under the present illness. The provider typically completed this section while performing the physical exam
Systems review or Review of systems
Patient gets to the point where they are ready to make the best of the diagnosis. They may be willing to use community resources for education and support
Acceptance
Information includes purpose for visit with patient's words in quotation marks or a summary of the patient's statement about the chief complaint
S- subjective data
This area addresses how the family and employer will respond to the demands of the diagnosis? Do they have a support system that will assist them in making healthy lifestyle choices?
Sociocultural
Patient tries to reverse a negative feeling to something that indicates the opposite feeling. Ex: if patient feels angry about diagnosis they may say "Don't worry, I'm not upset at you for telling me this"
Undoing
A summary of the previous health. It includes dates and details of the patients usual childhood diseases, major illnesses, surgeries, allergies, accidents, and immunizations
Past history or past medical history
Patient is unwilling to accept the reality of the situation and refuses to discuss the health problems or remember teaching interventions
Denial and isolation
This is the assessment of the patient's understanding of the treatment or of the person's ability to comply with the treatment plan. It may also be used to document follow-up
E - evaluation
This area focuses on if their beliefs affect compliance with treatment
Spiritual
Patient redirects negative feelings into a productive activity. Ex: patient becomes a member of a local support group for disease
Sublimation
This section includes information about the patients lifestyle including whether they feel safe at home, use of tobacco, alcohol, or recreational drugs, diet and exercise habits, education and occupation, if sexually active,cultural and religious background
Social history
Patient tries to "buy" privileges or time. Comments could include "I know I'm supposed to start this new treatment but something important is happening next week and I start afterwards."
Bargaining
Usually after this the provider had a preliminary diagnosis or working diagnosis of the cause of the patients chief complaint. The MA is not involved in this area
A- assessment
This area addresses if the patient can afford recommended treatments, do they have health insurance or do they need assistance with ongoing diagnostic and treatment recommendations
Economic