18 Questions
What should the history taker do when dealing with patients who have cognitive, mood, or communication deficits?
Seek information from additional sources, such as family members or medical records
What is the potential consequence of relying on previous medical records?
Inaccurate information may be repeated from provider to provider
What is the primary purpose of using an interpreter during a medical examination?
To facilitate communication between the patient and physician
What is the term used to describe inaccuracies in medical records that are repeated from provider to provider?
Chart lore
What is the primary source of information during a medical examination?
The patient themselves
What should the physician do when documenting information from sources other than the patient?
Clearly reflect the source of the information in the documentation
What is a potential psychological impact of litigation on a patient?
Source of anxiety, depression, or guilt
Why is it important to ask about family history during patient assessment?
To understand genetic disorders and provide insight into family members' ability to provide functional assistance
What is the primary goal of a detailed review of organ systems during patient assessment?
To discover any problems or diseases not previously identified during the course of the history taking
What is a common characteristic of neurologic problems in the setting of inpatient and outpatient rehabilitation?
Functional deficits in persons with various conditions
Why is it essential to ask patients about their family members' health?
To identify genetic disorders and provide insight into family members' ability to provide functional assistance
What can a patient's legal representative play a crucial role in obtaining?
Needed services and equipment
What is the primary goal of assessing the premorbid need for assistive devices, orthoses, and the degree of speech, swallowing, and cognitive impairments?
To understand the pathophysiology and location of the impairment
Why is it important to gather a complete list of medications being used by patients who are seeing multiple physicians?
To identify potential medication errors
What is a major push of the National Patient Safety Goals initiative?
Decreasing medication errors through medication reconciliation
Why is it essential to pay particular attention to nonsteroidal anti-inflammatory agents?
All of the above
What should physicians explain to patients about their prescribed medications?
The indications, precautions, and side effects
Why should patients be asked about their medications in detail?
Because patients might not mention medications that they do not think are relevant to their current problem
Learn about the importance of patient information in medical history taking, including the role of patients as primary sources and alternative sources for those with communication deficits.
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