Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
35 Cards in this Set
- Front
- Back
|
Purpose of the Medical History
|
Basis for all treatment rendered by the physician or provider.
Help ensure a complete treatment. Legal Record. |
|
|
A medical health history includes:
|
medical history, family history, social and occupational history, ROS
|
|
|
SOAPER
|
subjective
objective assesment plan education response of pt |
|
|
CHEDDAR
|
chief complaint
history examination details of problems drugs and dosages assessment return visit |
|
|
3 of 6 C's of charting
|
clarity, concise, complete
|
|
|
HIPAA
|
health insurance portability and accountability act of 96
|
|
|
3 supplies needed for eye instillation
|
sterile cotton balls, sterile gloves, tissues
|
|
|
ROS
|
Review of systems
|
|
|
What does s/s stand for?
|
signs and symptoms
|
|
|
2 types of exams
|
complete, limited
|
|
|
3 parts to a physical exam
|
health history, physical exam, tests:labs/diagnostics
|
|
|
5 MA responsibilites of preparing the exam room
|
clutter free, check and stock room supplies, empty trash/line it, check temp, change table paper.
|
|
|
6 vitals performed in PE
|
T, P, R, Ht, Wt, O2
|
|
|
6 methods of examinations
|
inspection=look
palpation=touch percussion=tapping auscultation=listen mensuration=measure manipulation=movement |
|
|
5 of the 10 positions
|
high-fowlers, dorsal recumbent, lithotomy, supine, prone
|
|
|
4 components of routine physical exam: patient appearance
|
gait, posture, speech, breath odor
|
|
|
4 components of routine physical exam: systemic exam.
|
head and neck, eyes, ears, nose
|
|
|
abdominal quadrants
|
RU hypochondriac, epigastric, LU hypochondriac
RM lumbar, umbilical, LM lumbar RL inguinal, hypogastric, LL inguinal |
|
|
5 of 10 supplies needed for PE
|
stethoscope, tongue depressor, pen light, tuning fork, reflex hammer
|
|
|
how to correct mistake
|
draw one line thru, make correction, write corr and initials.
|
|
|
4 times a day
|
QID
|
|
|
HEENT
|
head, eyes, ears, nose, throat
|
|
|
POMR
|
problem oriented medical record
|
|
|
uchd
|
uncommon childhood diseases
|
|
|
vs
|
vital signs
|
|
|
stat
|
immediately
|
|
|
twice a day
|
BID
|
|
|
FH
|
family history
|
|
|
Pt
|
patient
|
|
|
PE
|
Physical Examination
|
|
|
LMP
|
last menstrual period
|
|
|
SH
|
social history
|
|
|
Dx
|
diagnosis
|
|
|
PMH
|
past medical history
|
|
|
CC
|
chief complaint
|
