Card Set Information
What is the process of clinical reasoning?
Assessment & plan
What is the record of Mrs. N & the challenges of clinical data?
Recording your findings
What is the checklist for a clear & accurate record?
Recording your findings
What is the integration of clinical reasoning, assessment, and analysis of clinical evidence?
What is the information gathered in the health history from the patient or family termed?
What is the information gathered in the health history from the physical examination & lab tests termed?
What are the appropriate steps in identifying problems & making your diagnoses?
Identify abnormal findings
Localize findings anatomically
Develop plan that patient agrees
When generating the problem list, how do you make the list?
List most active & serious problems first while recording their date of onset
What are the challenges that you will face when dealing with clinical data?
Clustering data into single vs multiple problems
Sifting through an extensive array of data
Assessing the quality of data
What is one of the most important adjuncts to patient care?
Clear, well-organized clinical record
What should your goal be as a clinician when recording your findings?
To report a clear, concise but comprehensive report that documents key findings of patient assessment & communicates patients problems in a succint & legible format
What are some tips for ensuring the quality of patient data?
Open mind to patient
Apply principles of data analysis
Describe the acronym "SnNout"
Sensitivity of sympton is high, Negative response rules out target disorder
Describe the acronym "SpPin"
Specificity is high, positive test result rules in target disorder
What are the interviewing milestones that you as a clinician need to know?
Adapting to specific situations
Why is self-reflection important for professional development in clinical work?
It brings a deepening personal awareness to our work w/patients
How should the clinician get ready for the interview or approach be?
Review their clinical behavior/appearance
How should the sequence for the interview be carried out?
Greet & establish rapport w/patient
Inviting to patient's story
Notice emotional cues
Shared understanding of problem
What is an appropriate response technique for responding to emotional cues?
Naming-sounds like a scary exp
Understand-its understandable that you feel that way
Respecting-you've done better than most people would with this
What are the 7 attributes of a sympton?
Setting in which it occurs
Remitting or exacerbating factors
When asking the patient about the location of sympton what do you want to know?
Where is it?
Does it radiate?
When asking the patient about the quality of sympton what do you want to know?
What is it like?
When asking the patient about the quantity or serverity of a sympton what do you want to know?
How bad is it using a scale of 0-10
When asking the patient about the timing of a symptom it is important to note what?
When did it start?
How long it lasts?
How often does it come?
When asking the patient about setting in which symptoms occurs note what?
Circumstances that may contribute
When asking the patient about exacerbating factors what is important to note?
What makes it feel better or worse?
When asking the patient about associated manifestations of a symptom note what?
If anything else accompanies it
What is important to note when exploring the patients perspective?
What are the techniques of skilled interviewing?
Guided questioning: options for expanding & clarifying patient's story is done how?
Open-ended to focused questions
Questions that elicit graded resp
Series of questions-1 at time
Multiple choices for answers
How can you empower the patient that shows principles of sharing power?
Show interest in person
Follow their lead
Share information at transition points
Clinical reasoning transparent
Reveal limits of your knowledge
What are the general guidelines for broaching sensitive topics?
Explain why you need certain info
Consciously acknowledge whatever discomforts you are feeling
When asking about sexual hx what general questions should you ask?
Last time you had intimate contact
Sex w/men, women, or both
Number of partners in last 6 mo's
Concerns about HIV or AIDS
The CAGE questionnaire is helpful when dealing with what types of questions?
Alcohol & Drugs
Cage represents what?
Annoyed by criticsm
A good question for opening the lines of communication concerning illicit drugs?
Have you ever used any drugs other than those required for medical reasons
What are some possible clues to possible physical abuse?
Repeated injuries or accidents
Alcohol or drug abuse
Partner dominates interview
What are the 3 dimensions of cultural humility?
What are the 4 building blocks of professional ethics in patient care?
What are the tavistock principles?