Health assessment midterm study guide.docx

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Building A Complete Health History (Week 1) Chapters 1 & 26 • Communication techniques used to obtain a patient’s health history Chapter 1 - Open ended questions: gives the patient discretion ab... out the extent of the answer - Direct question: seeks specific information - Leading question: most risky, may limit information - Courtesy, comfort, connection, confirmation - CAGE questionnaire screening: designed to help diagnose alcoholism - CRAFT screening: ETOH and substance abuse in adolescents (Car, Relax, Forgot, Friends, Trouble) - TACE screening: drinks does it take to feel high, people Annoyed you about your drinking, Cut back drinking, Eye opener drink in the AM - Partner violence screen (PVS): hit kicked or punched, feel unsafe… - Domestic Violence (HITS): Hurt you physical, Insult you, Threaten you, Scream at you? - Spirituality (FICA): Faith, Importance, Community, Address - Types of histories: Complete, inventory (touches up on major points), Problem (focused, acute life-threatening problem), Interim (designed to chronicle events that have occurred since last meeting) - Recording and documenting patient International Classification of Disease (ICD): diagnostic coding system that classifies diseases and injuries and u used to track mortality and morbidity [Show More]

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