9 Questions
True or false: Presenting complaints should only be recorded if the patient is able to speak?
False
True or false: The patient's and the informant's version of the presenting complaints should be recorded separately?
True
True or false: Leading questions such as 'What brings you here today?' should be avoided when recording presenting complaints?
False
True or false: Presenting complaints should be recorded in the patient's own words.
True
True or false: Presenting complaints should be recorded regardless of the patient's ability to speak.
True
True or false: It is important to record bizarre or irrelevant patient explanations as part of the presenting complaints.
True
Which of the following is NOT true about recording presenting complaints?
Leading questions such as 'What brings you here today?' should be asked when recording presenting complaints.
Why is it important to record presenting complaints in the patient's own words?
To accurately capture the patient's concerns and perspective.
When should presenting complaints be recorded?
Regardless of the patient's ability to speak and without considering the relevance of their explanation.
Study Notes
Recording Presenting Complaints
- Presenting complaints should be recorded regardless of the patient's ability to speak.
- The patient's and the informant's version of the presenting complaints should be recorded separately.
- Leading questions such as 'What brings you here today?' should be avoided when recording presenting complaints.
- Presenting complaints should be recorded in the patient's own words.
- It is important to record bizarre or irrelevant patient explanations as part of the presenting complaints.
- Recording presenting complaints in the patient's own words is important because it allows for accurate representation of the patient's symptoms and concerns.
- Presenting complaints should be recorded at the initial encounter with the patient.
Test your knowledge on documenting presenting complaints for admission. Understand the importance of recording the patient's own words and informant's version, even in special circumstances. Explore different ways to elicit the patient's problem or reason for the visit.
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