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Details

PT101 writing patient/client notes
Documenting the exam
17
Health Care
Undergraduate 1
11/06/2010

Additional Health Care Flashcards

 


 

Cards

Term
The examination section of a patients notes includes Three subsections.  They are:
Definition

History

Systems Review

Tests and measures

Term

History subheadings


Demographic information:

Definition

Patients Name

address

admission date

date of birth

sex

dominant hand

race

ethnicity

language

Education level

advanced directive preferences

Referral source

reasons for referral to therapy

Term

History subheadings;

 

Current conditions/chief complaints:

Definition

onset date of problem

any incident that caused or contributed to the problem

prior history of similar problems

how the patient is caring for the problem

what makes the problem better or worse

other practitioners the patient has seen for the problem

 

Term

History subheadings

 

Patient goals:

Definition
Patient/client and sometimes family goals for therapy as told to the therapist by patient or family
Term

History subheadings

 

Prior level of function:

Definition

level of function prior to the most recent onset of current complaint

if a chronic condition the function prior to the most recent onset of symptoms

Term

History subheadings

 

social history

Definition

cultural and religious beliefs that might effect care

who does the person live with prior to admission

who will the person live with after discharge

available social and physical supports now and after discharge

availability of a caregiver

Term

History subheadings

 

employment status:

Definition

does the patient work

full time

part time

Student

work at home/office

retired

Term

History subheadings:

 

Living environment:

Definition

assistive devices and equipment the patient uses

type of residence

info about the residence

     Steps-stairs-ramps-etc

use of community services such as:  home health services, meals on wheels, hospice, homemaking services, other programs

 

Term

History subheadings:

 

General health status:

Definition

Patients self rating of general health

any major life changes during preceding year

Term

History subheadings:

 

social/health habits:

Definition

smoke

drink

exercise habits

physical activities ie hangliding, base jumping, dancing, etc.

Term

History subheadings:

 

Family health history:

Definition

general screening for a family history of

heart diseae,

hypertension,

stroke,

diabetes,

cancer,

psychological conditions,

arthritis,

osteoporosis and

other conditions.

Term

History subheadings:

 

patient medical/surgical history:

Definition
Any patient reported medical surgical history
Term

History subheadings:

 

Functional status/activity level

Definition

mobility

transfers

gait

selfcare

home management

community, school and work activities

that apply to current condition

Term

History subheadings:

 

Medications:

Definition
Medications taken
Term

History subheadings:

 

growth and development:

Definition

most applicable to pediatrics

 

include developmental history

Term

History subheadings:

 

Other clinical testsL

Definition
other clinical tests the dates and findings of those tests.
Term
It is unnecessary to report the source of the information in the history section uless it
Definition

contradicts information given by another source

 

or

 

it is the patients belief and not factual or documented medically

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