Delmars Clinical Medical Assisting Ch. 11 + 12

Front 1

Questions to ask patients with cultural influence

Back 1

1. What do you think caused your problem?

2. When do you think it started?

3. What effect does it have on you?

4. What are your concerns about this problem?

5. What kind of treatment do you expect?

Front 2

Demographic Data Form

Back 2

Registerspatient’s: name, address, mailing address if different, home and work phone,cell phone, dob, last 4 of social, all insurance info, and release of info signature

Front 3

Financial Information Form

Back 3

Financialpolicy of the practice, including billing, insurance billing, co-paymentbilling, and any finance charges added to monthly billing

Front 4

Privacy Information Form

Back 4

Describespatient’s rights, the facilities’ practices related to PHI, and where and howto file a complaint if patients feel their rights have been violated (Example –brochure) Sometimes requires signature

Front 5

Release of Information Form

Back 5

Sentto former provider to obtain past medical records and can be used to allowsharing of information with family members at the request of the patient.

Front 6

Medical History Form

Back 6

-Present healthhistory, including why the patient is being seen

-Health history,both personal and family

-Social historyincluding marital status, sexual orientation, and occupation

-Military service,including dates and assignments (alerts provider so screen for common veteranillnesses and to inquire about Agent Orange exposure)

-Body systemsreview/questionnaire

-Medicationscurrently being taken, including OTC andprescription

-Provider’s review of systems (ROS) (Completed byprovider)

Front 7

Computerized Health History Patient Generated

Back 7

Patient responds on the computer to various questions and then reviews information with the medical assistant for completeness

Front 8

Computerized Health History Provider

Generated

Back 8

Medical Assistant completes the information on the screen during the patient interview

Front 9

Chief Complain

Back 9

Then problem that brings the patient to the provider; in patients words for specificity

Front 10

Characteristics of a CC

Back 10

Location: Area where symptom is

Radiation: Size of area

Quality: Describe symptom (tingling, ache, throbbing, stabbing, etc)

Severity: Of symptom, (keeps me awake atnight..);Scale 1-10

Associated Symptoms: Other symptomscaused by CC

Aggravating/Alleviating Factors: Whatmakes the symptoms worse/decrease

Timing: When symptoms started and what patient wasdoing at the time

Front 11

Medical Health History

Back 11

Personal Data from the demographic form

Chief Complaint as noted at each visit by MA

Present Illness; meds, allergies, other providers

Medical History

Family History

Social and Occupational History

Review of Systems by physician or provider

Front 12

SOAP/SOAPER

Back 12

Very common; SOAPERis becoming more commonSubjective data: in patient’s words; cannot be seen

Objective data: observable, measurable findings

Assessment: probable diagnosis (based on S and O)Plan for treatment: Meds, instructions, FU

Education: educating patient

Response:patient response to E and care given

Front 13

Medical History

Back 13

Includes all of the patient's health problems, major illnesses, and surgeries, meds and dosages and reasons for taking them, allergies to meds and specific allergic reactions

Front 14

Review of Systems (ROS)

Back 14

The provider will check the cardiovascular, respiratory, gastrointestinal, genitourinary, neurologic systems, extremities, musculoskeletal, and skin. (Not necessarily in this order)

Front 15

Clinical Diagnosis

Back 15

Results of examination and lab tests, together with history and patient symptoms help determine diagnosis

Front 16

Medical Records

Back 16

Contents:

-Informed consents forms

-Physical Examination Outcomes

-Lab and Diagnostic test results

-Providers diagnosis and plan of treatment

-Surgical Reports

-Progress Reports

-Follow up care

-Phone calls relate to care

-Discharge Summary

-Other communications (from other providers, labs, agencies_

-Patient records form other providers

-Medication History

Front 17

Continuity of Care

Back 17

Developed by

-American Academy of Family Physicians

-American Academy of Pediatrics

Standard for creating electronic records of patient's health; used for transporting between providers; intended to improve the continuity of patient care, reduce errors, and assure a minimum standard of information to be shared

Includes:

- Patient and provider info

- Insurance data

- Patient's Health Status

- Recent Care Given

- Recommendations for future care

- Reason for referral or transfer

Front 18

Source-Oriented Medical Record (SOMR)

Back 18

Chronological set of notes for each visit, beginning with the patient's first visit

Front 19

Problem-Oriented Medical Record

Back 19

A list of problems to be made, dated, and assigned numbers; 4 main components:

-Database: medical history, results from labs, and results of physical exams

-Problems list: each problem is listed individually and assigned a number and dated

-Diagnostic and Treatment Plan: lab and diagnostic test completed and providers plan for treatment

-Progress Notes: entered for every problem; includes patent's complaint, problems, condition, treatment, and responses

Front 20

Electronic Medical Records (EMR)

Back 20

A different mode of documenting and saving information related to patient's care; computer storage

Front 21

Baseline

Back 21

Impression of overall well-being of the patient

Front 22

Temperature

Back 22

Maintained and regulated by heat production/loss; body loses heat by a combination of 5 ways:

-Convection

-Conduction

-Radiation

-Evaporation:

-Elimination

Hypothalamus monitors blood temp and will trigger heat loss/production with as little as .04 degress F change in blood temp

Front 23

Convection

Back 23

Heat loss through skin; (fan on a hot day)

Front 24

Conduction

Back 24

Transfer of heat (from body to clothes

Front 25

Radiation

Back 25

Heat loss to cooler environment

Front 26

Evaporation

Back 26

Heat loss through vaporization of perspiration (sweating)

Front 27

Elimination

Back 27

Heat loss through intestinal, urinary, and respiratory tracts

Front 28

Average Body Temp for Adults

Back 28

98.6 F

OR

37.0 C

Front 29

Afebrile

Back 29

Absence of fever

Front 30

Febrile

Back 30

Fever is present

Front 31

Pyrexia

Back 31

Fever; body temp is increased beyond normal range

Front 32

Onset

Back 32

Time when fever begins

Front 33

Lysis

Back 33

Body temp gradually returns to normal after a period of fever

Front 34

Crisis

Back 34

Body tem decreases suddenly to normal levels; patient may perspire profusely

Front 35

Intermittent

Back 35

A fluctuating fever that returns to or below baseline, then increases again

Front 36

Remittent

Back 36

A fluctuating fever that does not return to the baseline temperature; fluctuates but remains increased

Front 37

Continuous

Back 37

A fever that remains above the baseline; does not fluctuate but remains fairly constant

Front 38

Disposable Thermometers

Back 38

Individually wrapped strips with heat sensitive dots that change color to indicate temperature

Front 39

Electronic/Digital Thermometers

Back 39

Hand-held unit with a probe tip that is inserted into the ear securely to make a seal

Front 40

Temporal Artery Thermometer

Back 40

Measures the temperature of the skin surface over the temporal artery

Front 41

Oral Temperature

Back 41

Disposable strips; Electronic thermometer

Front 42

Aural Temperature

Back 42

Measures the infrared waves produced by the tympanic membrane and records the temp in less than 2 to 3 seconds on a digital screen; through the ear

Front 43

Rectal and Axillary Thermometers

Back 43

Temperature taken through the rectum and under the arm pit

Front 44

Abbreviations for Temp Taking

Back 44

-R: Rectal

-A: Axillary

-Tym: Tympanic

-TA: Temporal Artery

Front 45

Abbreviation R

Back 45

Rectal

Front 46

Abbreviation Ax

Back 46

Axillary

Front 47

Abbreviation Tym

Back 47

Tympanic

Front 48

Abbreviation TA

Back 48

Temporal Artery

Front 49

Average Oral Temperature

Back 49

96.6 F

Front 50

Average Rectal Temperature

Back 50

99.6 F

Front 51

Average Axillary Temperature

Back 51

97.6 F

Front 52

Average Tympanic Temperature

Back 52

98.6 F

Front 53

Average Temporal Artery Temperature

Back 53

99.4 F

Front 54

Pulse

Back 54

Increased pressure passes through the arteries in a wave like movement resulting in a slight expansion of the arterial wall (contraction) when the heart relaxes, (relaxation), the pressure is decreased in the arteries, resulting in the wall returning to its previous position; one contraction and one relaxation of the heart together is equal to one heart cycle or heart beat

Front 55

Pulse Sights

Back 55

Head to Toe:

-Temporal Artery (head)

-Carotid Artery (neck)

-Apical Artery (apex of heart)

-Brachial Artery (inner elbow; antecubital)

-Radial Artery (wrist)

-Femoral Artery (groin area)

-Popliteal Artery (behind knee)

-Dorsalis Pedis (top of foot)

Front 56

Arrhythmia

Back 56

Abnormal rhythm in heart rate

Front 57

Average Pulse Rates

Back 57

-Birth: 120-170 bpm

-Infants: 100-150 bpm

-Children:

1yr: 120-160 bpm

2yr: 80-140 bpm

3yr: 70-120 bpm

7-14yr: 50-90 bpm

-Adults: 60-100 bpm

Should be recorded after temp

Front 58

Bradycardia

Back 58

Less than 60 bpm

Front 59

Tachycardia

Back 59

Greater than 100 bpm

Front 60

Eupnea

Back 60

Normal respiratory rate

Front 61

Normal Respiratory Rates

Back 61

-Newborns: 30-60 rpm

-Infants: 24-40 rpm

-Children (1-7yrs): 22-34 rpm

-Adults: 14-20 rpm

Front 62

Apnea

Back 62

Complete absence of breathing

Front 63

Tachypnea

Back 63

Greater than 40 rpm

Front 64

Bradypnea

Back 64

Less than 12 rpm

Front 65

Cheyne-Stokes

Back 65

Breathing pattern that starts with a period of apnea lasting 10-60 sec, followed by increasing depth and rate of respiration, which is then followed by a decrease in rate with apnea starting the cycle once again

Front 66

Orthopnea

Back 66

Severe dyspnea

Front 67

Dyspnea

Back 67

Labored breathing

Front 68

Hypoventilation

Back 68

When respiration is decreased in rate and shallow in depth

Front 69

Hyperpnea

Back 69

Respiration that is increased in both depth and rate

Front 70

Hyperventilation

Back 70

Type breathing in which the amount of oxygen drawn in during inspiration is greatly increased, resulting in a decrease in the amount of blood carbon dioxide

Front 71

Sleep Apnea

Back 71

Air flow during respiration that stops for more than 10 seconds

Front 72

Narcolepsy

Back 72

Causes excessive sleepiness and daytime sleep attacks

Front 73

Rales (rawles)

Back 73

Clicking or rattling sounds during respiration or expiration when the lung passageways contain secretions

Front 74

Rhonchi

Back 74

Sounds similar to snoring, usually produced by rattling in the throat

Front 75

Wheezes

Back 75

High pitched musical sounds heard on expiration

Front 76

Stridor

Back 76

Crowing sound heard on inspiration

Front 77

Stertorous

Back 77

Snoring sound with labored breathing

Front 78

Respiratory Sounds Through Auscultation

Back 78

-Rales

-Rhonchi

-Wheezes

-Stridor

-Stertorous

Front 79

Systole

Back 79

Force exerted on the arterial walls during cardiac contraction (highest)

Front 80

Diastole

Back 80

Force exerted during cardiac relaxation (lowest)

Front 81

Blood Volume

Back 81

Amount of blood within the arteries

Front 82

Peripheral Resistance

Back 82

Resistance to blood flow within the arteries

Front 83

Lumen

Back 83

Inside space of the vein

Front 84

Vessel Elasticity

Back 84

Ability of the arteries to expand and contract to provide a stead flow of blood

Front 85

Atherosclerosis

Back 85

Causes an increase in arterial wall resistance resulting in an increase in blood pressure

Front 86

Viscosity

Back 86

The property of a fluid that offers resistance to flow; thickness

Front 87

Aneroid Manometer

Back 87

A cuff containing a rubber bladder attached to a dial

Front 88

Digital Sphygmomanometer

Back 88

Automatic and registers blood pressure in digital form on a screen

Front 89

Pulse Oximeter

Back 89

Noninvasive method for measuring the amount of oxygen that is saturating the hemoglobin molecules contained in a red blood cell

Front 90

Korotkoff Sounds

Back 90

Sounds Heard during blood pressure measurement

-Phase I: First sound heard; sharp tapping sound; systolic reading

-Phase II: Soft swishing sound; increasing blood flow as cuff deflates

-Phase III: Rhythmic tapping sound; more blood flowing through; can be mistaken as systolic if phase I and II are missed

-Phase IV: Muffling and fading of the tapping sounds; blood flowing fairly easy and cuff is fully deflated

Phase V: No sounds; blood flowing freely; diastolic reading

Front 91

Normal Blood Pressure Readings

Back 91

-Child: 10 yr - 100/65

-Adolescent: 16 yr - 118/75

-Adult: Less than 120/ less than 80

-Prehypertension: 120-139/80-89

-High blood pressure: above 140/90

Front 92

Hypertension

Back 92

BP consistently above normal

5 types:

-Primary: No cause or cure, but treatable

-Secondary: Underlying issues; once underlying issue is gone BP returns to normal

-Benign: Slow progression but may have same result as malignant

-Malignant: Rapid progression with severe damage to cardiovascular system, possibly to the point of death

- White Coat Hypertension: Caused by anxiety or fear when having BP measured

Front 93

Hypotension

Back 93

BP consistently below normal; patient is unable to perform normal activities without dizziness and extreme fatigue