3068298
| Pregunta | Respuesta |
| Anticipation Skills | the ability to know what the provider needs without having to ask |
| Medical Assistant Boundries | -diagnostic testing w/ physicians order -patient preparation -screener -chief complaint -patient histories -vital signs |
| In Office Screenings | -obtain the chief complaint -update current med list -update allergy status -perform and document vital signs |
| Chief Complaint | -the complaint or reason that prompted the patient to seek medical attention -subjective information |
| History of the Present Illness (HPI) | a series of symptoms that are related to the patient's complaint |
| Breasts | -pain, tenderness, swelling, odor, change in size, history of breast disease -Disrobing: remove all clothing from the waist up -vitals: blood pressure (never take on same side as a mastectomy), weight -Supplies: culture supplies if drainage is present |
| Cardiovascular | -difficulty breathing, shortness of breath, chest pains or pressure, heart palpitations, nausea or vomiting -Disrobing: remove all clothing waist up -All Vitals - crash cart, AED, ECG, oxygen, IV materials |
| Ears | hearing deficits, ringing in ear, pain or discharge, build up of earwax, foreign body in ear -no disrobing -Vitals: temperature and blood pressure, weight, maybe audiometry -Supplies: Otoscope, ear irrigation equipment and solution, gauze |
| Eyes | visual disturbances, double vision. light sensitivty, excessive tearing, drainage, blind spots, foreign body in eye -no disrobing -vitals: blood pressure. weight, visual acuity testing -Supplies: cycloplegics, fluorescain dye, sterile swabs, gauze, pen light, opthalmoscope, and antibiotic drops |
| Documenting Chief of Complaint | -Location: general location of symptoms -Amount -Color: important for body fluids -Size: large, small -Pain: numeric scale or face scale -Duration or Date of Onset: the period of time the symptoms have occured -Related Symptoms: -current med list -listed drug allergies -closing, professional, signature |
| Standing Orders | a list of written orders -developed by the provider for procedures that were to be performed when the patient complained of specific symptoms |
| Provider's Role | -expanding HPI to include exact location, quality, severity, duration, timing, context, modifying factors, and associated symptoms -performing a review of symptoms -performing an examination, and document findings |
| Progress Note | -date and time -reason for the visit -current symptoms -patient's compliance or noncompliance to follow home care instructions -physical observations -closing signature |
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