40 Questions
What is the primary purpose of tailoring the data collection to the situation at hand?
To increase the accuracy of the data collected
What should be documented if an interpreter is required?
The use of a professional interpreter
Why should a professional interpreter be used instead of a family member or bilingual staff member?
To ensure accuracy and confidentiality
What should be included in the patient's occupational history?
Past and current employment, including occupational hazards
Why is it important to ask about a patient's hobbies?
To understand their interests and lifestyle
What can be identified through asking about a patient's daily activities and exercise?
Their overall health and wellness
Why is it important to ask about a patient's nutrition and diet?
To understand their beliefs about the role of diet in their health
What should be considered when asking about a patient's education?
The ability to read and write
What is the purpose of the AUDIT questionnaire?
To diagnose Alcohol Use Disorders
What is one of the questions asked in the AUDIT questionnaire?
Have you ever felt annoyed by people criticizing your drinking?
According to the AUDIT questionnaire, what is a sign of a person having a problem with drinking?
Feeling guilty about drinking
What is the purpose of the 'Cut Down' question in the AUDIT questionnaire?
To determine if a person needs to cut down on their drinking
What is the term for a person who has quit smoking?
Former tobacco user
What should be documented when taking a smoking history?
The number of years since quitting tobacco
What is the term for having a drink first thing in the morning?
Eye Opener
Who developed the AUDIT questionnaire?
The World Health Organization (WHO)
What is a sedentary lifestyle a risk factor for?
Certain diseases
Why is it important to assess the patient's eating habits?
To identify potential food allergies and intolerances
What is a potential indicator of regular aerobic exercise?
Frequency and duration of exercise
Why is it important to be specific when assessing a patient's daily activities and exercise?
To avoid vagueness and assess potential for trauma
What is a common problem when eliciting alcohol, smoking, and drug histories?
Assessing truthfulness
What should be ascertained when assessing a patient's use of alcohol, tobacco, and recreational drugs?
The amount, frequency, and context of use
Why may the word 'diet' be confusing for some patients?
Because they may not be following a certain weight reducing diet
What factors can affect a patient's dietary habits?
Income and ability to shop for and prepare food
What is a potential issue when asking patients about tobacco use?
Patients may provide ambiguous answers.
Why is it challenging to address recreational drug use and narcotic addiction?
Clinicians may be the patient's source of drugs.
What is an important distinction to make in a patient's life?
Between spirituality and religion.
How might a patient express their religious affiliation?
With a loose affiliation or no affiliation at all.
What is a potential impact of a patient's religious or cultural beliefs?
They can be a driving force in a person's life.
What might a patient's spirituality entail?
All of the above.
Why is it important to consider a patient's recreational drug use?
It can impact their overall health.
What can be a challenge when addressing a patient's addiction?
Clinicians may be the patient's source of drugs.
What is the purpose of inquiring about a patient's spiritual or religious beliefs?
To identify potential support systems
Why is it important to ask about a patient's relationships and support systems?
To identify potential caregivers
What is the primary goal of detecting abusive relationships?
To ensure patient safety and provide resources
Why is it important to ask about a patient's living situation and household members?
To identify potential caregivers and support systems
What is the purpose of asking about a patient's safety in their relationships?
To assess their risk of domestic violence
Why is it important to inquire about a patient's emergency plan?
To ensure they have resources in times of crisis
What is the goal of asking about a patient's feelings of safety in their relationships?
To detect potential domestic violence
Why is it important to explore a patient's relationships with friends and family?
To identify potential caregivers and support systems
Study Notes
Social Components of a Patient's History
- Demographics, education, occupation, and hobbies are essential components of a patient's history
- Nutrition and diet, including food intolerance, allergies, and ability to shop for and prepare food, affect a patient's health
- Daily activities and exercise, including sedentary lifestyle and potential for trauma, must be documented
- Residence and recent travel, including last grade level attended and ability to read and write, are important
- Marital status, children, and ethnic group are also crucial
Obtaining Intimate Data
- Obtaining intimate data is easier when you know the patient better
- Tailor the questions to the situation at hand
- Be aware of state laws and federal initiatives regulating the use of interpreters
Education and Occupation
- Document past and current employment, including occupational hazards and military service
- Ask questions like "Do you work outside your home?" and "What kind of work do you do?"
- Assess the patient's schedule, including shift work, and potential exposure to fumes, chemicals, dust, loud noise, or radiation
Nutrition and Diet
- Patients may have strong beliefs about diet and health
- Note specific food intolerance, food allergies, and condition of the patient's teeth
- Ask "Tell me about your eating habits" and assess the patient's ability to shop for and prepare food
Daily Activities and Exercise
- Document sedentary lifestyle and potential for trauma
- Ask specific questions about exercise, including type, frequency, and duration
- Assess the patient's hobbies and potential for sports-related injuries
Alcohol, Tobacco, and Recreational Drug Use
- Assessing truthfulness is a common problem when eliciting alcohol, tobacco, and drug histories
- Ascertain the amount, frequency, and context of the patient's use of these substances
- Use tools like the CAGE questionnaire to detect alcohol use disorders
Spirituality, Religion, and Beliefs
- Spirituality and religion are not necessarily the same thing
- Document the patient's beliefs and their importance in their life
- Ask questions like "Do you consider yourself a spiritual or religious person?" and "How do these beliefs influence your health care?"
Relationships and Abuse
- Document the patient's relationships, including family members and support systems
- Ask about domestic violence, detecting relationships that are physically or emotionally abusive
- Use safe questions to detect abuse, such as "Do you feel safe in your relationships?" and "Have you or your children been physically hurt or threatened?"
Learn about the social components of patient history, including demographics, education, occupation, and daily activities, to provide better healthcare.
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