NURS 6512 Midterm Exam Review (Week 1-6) GradeAplus

Building A Complete Health History

1. Communication techniques used to obtain a patient’s health history

Courtesy, Comfort, Connection, Confirmation

(i.e. knock on door before entering, learn their names, ensure confidentiality, ensure good lighting &

temperature, don't overtire patient, maintain good eye contact, watch your language, avoid being

judgemental, conduct a CPE, avoid leading or directing an answer, ask the patient to summarize

discussion, allow time for questions, be honest if you do not know the answer)

2. Recording and documenting patient information

Documentation is most important:

•Chronologically documents the care of the patient & contributes to high-quality care

•Primary means of communication between healthcare team members which facilitates continuity

care & communication among those involved with the patient's care

•Establishes your credibility as a healthcare provider (i.e., use professional language, include

appropriate content)

•Legal implications:

• Provides evidence that appropriate care was given & how the patient responded to the care

provided

• "If it was not documented, it was not done" - quote is important with considerable time-lapse

that in a event where you may have to recall the events that occurred in court

•The Centers for Medicare and Medicaid Services (CMS) requires: (Sullivan, 2012, p. 2)

1. The medical record should be complete and legible

2. The documentation of each patient encounter should include the following:

•Reason for the encounter and relevant history, physical exam findings, and diagnostic test

results

•Assessment, clinical impression, or diagnosis

•Plan for care

•Date and legible identity of the observer

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be

easily inferred

4. Past and present diagnoses should be accessible to the treating and consulting providers

5. Appropriate health risk factors should be identified.

6.The patient's progress, response to and changes in treatment, and revision of diagnoses should

be documented

7. The Current Procedural Terminology (CPT) and ICD-9 codes reported on the health insurance

claim form or billing statement should be documentation. (Examples of how to document ICD

code are on page 5 of Sullivan's).

• Maintain patient confidentiality (HIPPA)

• Patients and their respected parties have the right to view medical records with limitations (i.e.,

psychiatric patients cannot view provider's notes)

The Comprehensive History & Physical Exam

• Documents the patient's medical history, physical exam findings, diagnoses or medical problems,

diagnostic studies to be performed, and initial plan of care implemented to address any problems

identified. 

•Do not copy another provider's H&P- always perform your own and if unable to then give credit to

the provider responsible

•History includes: patient's personal identification

•Chief Complaint (CC)- why is the patient there? (Best stated in the patient's own words)

•History of the Present Illness or History of the CC: the chronological description of the development

of the patient's present illness from the first sign or symptom of the presenting problems. Include

identifying elements such as location, quality, severity, duration, timing, content, modifying factors, &

associated sign and symptoms.

•Past Medical History: documents the patient's past and current health. Includes: Past medical history,

past surgical history or other hospitalizations (provide dates if possible), medications, drug allergies,

and health maintenance and immunizations.

•Family History: first-degree relatives includes parents, grandparents, and siblings with the age their

age and status. If deceased, include the age at time of death and cause of death.

Psychosocial History: Identify factors that may influence the patient's overall health or behaviors that

places the patient at risk for specific conditions. Includes patient's sexual orientation, marital status,

children, occupation status, environmental risks, language preference (if interpreter required, it must

be documented), religion/ cultural beliefs, tobacco/etoh/illicit drug use, diet, etc.

• Review of Systems (ROS): an inventory of specific body systems designed to document any

symptoms the patient may be experiencing or has experienced. Includes positive and negative

responses from patient

• Physical Examination: may confirm or refute a diagnosis suspected from the history and provide a

more accurate problem list.

• Laboratory & Diagnostic Studies: laboratory tests, radiographs, or other imaging studies with

specific values/results which allows readers to formulate their own conclusions, documents baseline

values, and saves time for other readers to look values.

• Problem List, Assessment, and Differential Diagnosis: provider evaluates all the info to identify the

patient's problems in a numbered list (includes date of onset and whether active/inactive) with the

most severe problems listed first.

• Plan of Care: document any additional studies or workup needed, referrals or consults needed,

pharmacological management, nonpharm.or other management patient education, and disposition (i.e.,

"return to clinic" or "admit to the hospital"

3. SOAP note documentation

SOAP note documentation is the comprehensive history and physical examination documented in a

format.

S – Subjective: includes chief complaint (CC), history of present illness (HPI), Pertinent past medical

history (PMH), Pertinent family history (FH), Pertinent psychosocial history (SH), any specialized

history related to the chief complaint, and Pertinent review of systems (ROS) (Sullivan, pp.91-92).

O – Objective: includes the vital signs, a general assessment of the patient, physical examination

findings, results from laboratory or diagnostic tests (Sullivan, p. 93)

A – Assessment: is an analysis and interpretation of the subjective and objective data to provide a

diagnosis or a list of differential diagnoses (Sullivan, pp. 96-97).

P – Plan: this area includes diagnostic studies that will be obtained, referrals, therapeutic interventions,

educational material, disposition of the patient, next visit (Sullivan, p. 99).

4. Subjective vs objective information when documenting

Subjective is the history given by the patient that guides the physical objective examination (Sullivan,

p. 91).

Subjective information is based on personal opinions, interpretations, points of view, emotions and

judgment. Objective information or analysis is fact-based, measurable and observable.

5. Ethical decision-making and beneficence

•Beneficence: "The principle of acting with the best interest of the other in mind. It is the basic

premise that healthcare providers have a duty to be of a benefit to the patient as well as to take

positive steps to prevent harm from the patient." (Levitt, 2014).

•"Practitioners need to be aware and make practice decisions from good quality scientific evidence as

well as clinical judgment considerations with individual patients" (Dains, Baumann, & Scheibel, 2016,

p. 10).

•"Not all diseases or conditions are appropriate for screening. The purposes of screening must be

ethically acceptable, information must be used for appropriate purposes, tests must be of high quality,

individuals should know what is taking place and informed of their results, counseling must be

available to interpret results, and results must be kept confidential" (Dains et al., 2016, p. 8).

• Guidelines to determine if appropriate to screen:

1. Is the condition significant in the community?

-Morbidity and mortality data must justify if the condition has a significant impact on quality

and quantity of life. Does it justify the cost to screen?

2. Can the condition be screened?

-Tests must be at a reasonable cost and is determined by the sensitivity (ability to provide a

true positive), specificity (ability to provide a true negative), reliability (reproducibility), and

validity (does it measure what you think it measures?).

3. Should the conditions be screened?

-"Before screening can be recommended, acceptable treatments must be available." Once the

condition is detected, will the treatment have a significant impact to improve the health

outcomes?

• The United States Preventive Services Task Force (USPSTF): independent group of experts in

prevention and evidence-based medicine; Makes recommendations about clinical preventive services

such as screenings, counseling, and preventive medications.

-Works with the Evidence-Based Practice Centers (EPCs) to conduct in-depth systematic

reviews of available evidence and develop a analytic framework

Diversity and Health Assessments

6. Cultural awareness and diversity

*Cultural reflects the whole of human behavior including ideas and attitudes; ways of relating,

speaking manners, products of physical effort, ingenuity and imagination.

*Cultural awareness- being knowledgeable of one’s thoughts, feelings, sensation and how these things

affect interactions

Crossing the cultural divide helps, but skepticism is a barrier.

*Cultural humility- recognizing one’s limitation in knowledge and cultural perspective to be open to

new perspectives; view each patient individually

*Seeleman et al framework- emphasizes on awareness of social context which specific ethnic groups

live Social context in minority group means assessing stressors and support networks, sense of life

control and literacy

*Campinha- Bacote’s process of Cultural Competence Model- includes (cultural competence

dimensions): Awareness- self- examination and in -depth exploration of your biases, stereotypes,

prejudices, and assumption

Knowledge- seeking and obtaining education

Skill- collecting culturally relevant data assessing in a cultural manner

Encounter- patient interactions used to validate, redefine or modify existing beliefs and practices and

develop cultural desire or modify existing beliefs and practices and develop cultural desire awareness,

skill, and knowledge

Desire- motivation to want engagement in being culturally competent

Siedel- pp. 22- 23

7. Socioeconomic, spiritual, and lifestyle factors affecting diverse populations

Culturally competent care requires that health care providers be sensitive to patients’ heritage, sexual

orientation, socioeconomic situation, ethnicity, and cultural background. Cultural encounters: the

continuous process of interacting with patients from culturally diverse backgrounds in order to

validate, refine, or modify existing values, beliefs, and practices about a cultural group and to develop

cultural desire, cultural awareness, cultural skill, and cultural knowledge. Cultural Desire: the

motivation of the health care professional to “want to” engage in the process of becoming culturally

competent, not the “have to”. Cultural Awareness: the deliberate self-examination and in-depth

exploration of one’s biases, stereotypes, prejudices, assumptions and “isms” that one holds about

individuals and groups who are different from them. Cultural Knowledge: the process of seeking and

obtaining a sound educational base about culturally and ethnically diverse groups. Cultural Skill: the

ability to collect culturally relevant data regarding the patient’s presenting problem, as well as

accurately performing a culturally-based physical assessment in a culturally sensitive manner. Poverty

and inadequate education disproportionately affects various cultural groups; socioeconomic disparities

negatively affect the health and medical care of individuals belonging to these groups. The health care

provider must be open and willing to understand individual’s different spiritual rituals. When cultural

differences exist, be certain that you grasp exactly what the patient means and know exactly what the

patient thinks you mean in words and actions.

8. Functional assessments

Functional assessment is an attempt to understand a patient’s ability to achieve the basic activities of

daily living. This assessment should be made for all older adults and for any person limited by disease

or disability, acute or chronic. A well-taken history and a meticulous physical examination can bring

out subtle influences, such as tobacco and alcohol use, sedentary habits, poor food selection, overuse

of medications (prescribed and non-prescribed), and less than obvious emotional distress. Even some

physical limitations may not be readily apparent. Keep in mind that patients tend to overstate their

abilities and, quite often, to obscure reality. When performing a functional assessment consider a

variety of disabilities: physical, cognitive, psychologic, social, and sexual. An individual’s social and

spiritual support system must be as clearly understood as the physical disabilities. There are a variety

of physical disabilities, including: mobility, upper extremity function, housework, and instrumental

activities of daily living