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Questions and Answers
What is the primary purpose of the HPI section in a patient's medical history?
Which type of information is obtained through observation, physical examination, and laboratory and diagnostic testing?
What is the purpose of the 'denies' statement in the Review of Systems section?
What is the last question that should be asked in any patient interview?
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What is the purpose of the CC section in a patient's medical history?
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What is the difference between a comprehensive assessment and a focused assessment?
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What is the primary goal of primary prevention?
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Which type of prevention is exemplified by blood pressure screenings?
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What is the primary focus of a problem-focused exam?
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Which level of medical decision making is characterized by a low complexity?
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What is the primary goal of counseling and coordination of care?
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Which level of evaluation and management involves a comprehensive review of the patient's medical history?
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What is the primary goal of tertiary prevention?
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Which type of exam is characterized by a general multi-system exam or complete exam of a single organ system?
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What is the primary goal of a comprehensive level of evaluation and management?
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Which level of medical decision making is characterized by a high complexity?
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What is the primary importance of confidentiality when discussing sensitive topics with patients?
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What is the purpose of assessing a patient's personal beliefs about health?
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What is the function of the MMSE Mini Mental State Exam?
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What is the purpose of using the 2-question depression screening tool?
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What is the significance of assessing a patient's functional capacity using the Duke Activity Index?
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What is the primary component of the HPI?
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What is the significance of asking 'Have you ever had this before?' in the HPI?
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What is the significance of optimal weight and nutrition in health promotion and counseling?
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What is the purpose of the PHQ-9 in assessing depression?
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What is the significance of cultural competence in healthcare?
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Study Notes
Understanding Subjective and Objective Information
- Subjective information includes the client's point of view, feelings, perceptions, and concerns obtained through interviews
- Chief complaint: the reason the patient is seeking assistance, written in quotes
- HPI (History of Present Illness): a detailed description of the primary problem using symptom analysis
- PQRST: Past medical history, including immunizations, allergies, and responses
Components of a Full and Focused Exam
- Comprehensive Assessment:
- Identifying data and source of the history
- Reliability
- CC (Chief Complaint)
- HPI (History of Present Illness)
- PQRST
- Past medical history, including immunizations, allergies, and responses
- Family history
- Personal and social history
- Review of systems (head to toe subjective data)
- Focused Assessment:
- Identifying data
- CC
- HPI
- Data from PMH, FH, SH that pertains to the complaint
- ROS (Review of Systems) that pertains to the complaint
Approaches to Discussing Sensitive Topics
- Be aware of self and how personal judgments affect thinking
- Confidentiality is of high importance
- Patient's autonomy cannot be ignored
- Be direct and firm
- Do not apologize for questions
- Do not preach
- Do not push too hard
- Be ready to explain why you need to ask
- Explore patient's feelings
- Offer patient opportunity to ask questions
- Use gender-neutral language
Cultural Competence
- Assess patient's personal beliefs about health
- What religious influences may affect care?
- What language is primary?
- What are the roles in the family?
- Are there special dietary practices that may influence compliance or recovery?
- Recognize diversity
- Demonstrate respect for the unfamiliar
- Identify own cultural beliefs
- Don't stereotype
- Learn the facts
- Develop a plan with culture in mind
Assessment Tools
- 2-question depression screening:
- In the last month, have you been bothered by little interest or pleasure in doing things?
- Feeling down, depressed, or hopeless?
- MMSE (Mini-Mental State Exam):
- Standardized screening tool for mental status
- Max score: 30
- Depressed clients w/o dementia score 24-30
- Score of 20 or less is found with dementia, delirium, schizophrenia, or an affective disorder
- MOCA (Montreal Cognitive Assessment):
- Brief (10-minute) screening tool for mild cognitive impairment
- More sensitive for early or mild impairment, a risk factor for dementia
- Normal score: 26-30
- Lower score requires more in-depth assessment
- Beck's Depression Scale:
- Assesses severity of depression in adults and adolescents (13 and up) without a diagnosis of a psychiatric illness
- Not a sole diagnostic measure
- Highly reliable
- Score of < 15: mild depression
- Score 15-30: moderate depression
- Score > 30: severe depression
- PHQ-9:
- Rates the frequency of symptoms to score severity
- Can be utilized multiple times to show trends
- Question 9 asks about suicide ideation
- Score 5-9: minimal symptoms
- Score 10-14: mild depression
- Score 15-19: major depression, moderately severe
- Score > 20: major depression, severe
- Duke Activity Index:
- Self-administered questionnaire that measures a patient's functional capacity
- Can be used to get a rough estimate of a patient's peak oxygen uptake
- Assesses the functional capacity of patients with cardiovascular disease
- Final score ranges between zero and 58.2 points
- The higher the score, the better the functional capacity
HPI Components
- Complete, clear, and chronologic description of the problems prompting the patient's visit
- Symptom Analysis:
- P: precipitating/palliative/provocative
- Q: Quantity or Quality
- R: Region/Radiation
- S: Severity
- T: Timing
- Most important: HAVE YOU EVER HAD THIS BEFORE?
Health Promotion and Counseling
- Optimal weight, nutrition, and diet
- BMI > 25: risk for heart disease, HTN, high LDL, low HDL, high triglycerides, hyperglycemia
- Blood pressure and dietary sodium
- A difference of 5g of salt intake a day is linked to a 23% difference in the rate of stroke and a 17% difference in the rate of total cardiovascular disease
- Daily dietary intake of 2300 mg is tolerable
- Exercise
- Tobacco cessation
Billing Types and Time
- Problem-focused: CC, brief HPI
- Expanded problem-focused: CC, limited exam of affected body area or organ system and other symptomatic or related organ system
- Detailed: CC, extended HPI, problem pertinent ROS and other additional pertinent PMH, SH &/or FH related to problem
- Comprehensive: CC, extended HPI, full ROS, complete past, family, and social history
Complexity of Medical Decision Making
- Straightforward
- Low complexity
- Moderate complexity
- High complexity
Type/Definition of Each of the 5 Billing Levels
- Levels of Evaluation and Management:
- Level 1: straightforward
- Level 2: low complexity
- Level 3: moderate complexity
- Level 4: high complexity
- Level 5: high complexity with multiple conditions
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Description
Learn the difference between subjective and objective information in nursing assessment. Understand how to gather data from the client's point of view and observable signs. Test your knowledge of chief complaint, HPI, and symptom analysis.
