Medical History Taking

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Questions and Answers

What should the history taker do when dealing with patients who have cognitive, mood, or communication deficits?

  • Use a standardized questionnaire to assess their condition
  • Rely solely on the patient's self-report
  • Seek information from additional sources, such as family members or medical records (correct)
  • Focus on the patient's physical symptoms rather than their mental state

What is the potential consequence of relying on previous medical records?

  • Inaccurate information may be repeated from provider to provider (correct)
  • The patient's medical history may be overlooked
  • The physician may overcharge for their services
  • The patient's care may be delayed due to incomplete records

What is the primary purpose of using an interpreter during a medical examination?

  • To provide emotional support to the patient
  • To facilitate communication between the patient and physician (correct)
  • To ensure the patient's privacy is maintained
  • To assist the physician in taking notes

What is the term used to describe inaccuracies in medical records that are repeated from provider to provider?

<p>Chart lore (D)</p> Signup and view all the answers

What is the primary source of information during a medical examination?

<p>The patient themselves (A)</p> Signup and view all the answers

What should the physician do when documenting information from sources other than the patient?

<p>Clearly reflect the source of the information in the documentation (A)</p> Signup and view all the answers

What is a potential psychological impact of litigation on a patient?

<p>Source of anxiety, depression, or guilt (A)</p> Signup and view all the answers

Why is it important to ask about family history during patient assessment?

<p>To understand genetic disorders and provide insight into family members' ability to provide functional assistance (D)</p> Signup and view all the answers

What is the primary goal of a detailed review of organ systems during patient assessment?

<p>To discover any problems or diseases not previously identified during the course of the history taking (D)</p> Signup and view all the answers

What is a common characteristic of neurologic problems in the setting of inpatient and outpatient rehabilitation?

<p>Functional deficits in persons with various conditions (C)</p> Signup and view all the answers

Why is it essential to ask patients about their family members' health?

<p>To identify genetic disorders and provide insight into family members' ability to provide functional assistance (B)</p> Signup and view all the answers

What can a patient's legal representative play a crucial role in obtaining?

<p>Needed services and equipment (A)</p> Signup and view all the answers

What is the primary goal of assessing the premorbid need for assistive devices, orthoses, and the degree of speech, swallowing, and cognitive impairments?

<p>To understand the pathophysiology and location of the impairment (D)</p> Signup and view all the answers

Why is it important to gather a complete list of medications being used by patients who are seeing multiple physicians?

<p>To identify potential medication errors (B)</p> Signup and view all the answers

What is a major push of the National Patient Safety Goals initiative?

<p>Decreasing medication errors through medication reconciliation (A)</p> Signup and view all the answers

Why is it essential to pay particular attention to nonsteroidal anti-inflammatory agents?

<p>All of the above (D)</p> Signup and view all the answers

What should physicians explain to patients about their prescribed medications?

<p>The indications, precautions, and side effects (C)</p> Signup and view all the answers

Why should patients be asked about their medications in detail?

<p>Because patients might not mention medications that they do not think are relevant to their current problem (A)</p> Signup and view all the answers

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