During the review of systems, the interviewer must document:

Presence or absence of all symptoms under the system heading

Functional assessment includes assessment of self-esteem. Areas covered under this include:

education & training, financial status, value-belief system

What additional information is added when a health history is taken on an infant?

Prenatal/natal history, growth & development, immunizations

You question the reliability of the history given by the patient. One way to verify info is to:

rephrase the same questions later in the interview

Select the best description of "review of systems."

An eval. of past & present health status of each body system

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N1I02 - Health Assessment

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The health assessment

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Questions 8

Answers

1
During the review of systems, the interviewer must document:
Presence or absence of all symptoms under the system heading
"negative" under the system heading.
physical findings, ie heart rate, to support historic data.
All of the above
2
You ask, "What makes the headaches worse?" With this question you are seeking information about
associated symptoms
severity
aggravating factors
the patient's perception of the pain
3
Which of the following is included in documenting a history source?
Documented relationship of support systems
reliability of the informant
cognition and literacy level
appearance, dress, hygiene
4
Functional assessment includes assessment of self-esteem. Areas covered under this include:
stressors, coping mechanisms, change in past year
education & training, financial status, value-belief system
family role, interpersonal relations, social support
exercise, leisure activities, level of independence
5
What additional information is added when a health history is taken on an infant?
Prenatal/natal history, growth & development, immunizations
Environmental hazards and use of safety mechanism at home
Type of nutritional intake
Family communication patterns and interactions
6
You question the reliability of the history given by the patient. One way to verify info is to:
call a family member to confirm information.
review previous medical records.
rephrase the same questions later in the interview
ask the patient if there is someone who can verify the info
7
PQRSTU - a mnemonic that helps the clinician to remember to address characteristics specific to
symptoms
substance use and abuse
ability to perform ADLs
severity of dementia
8
Select the best description of "review of systems."
A record of objective findings
A short statement of general health status
A documentation of the problem as perceived by the patient
An eval. of past & present health status of each body system

N1I02 - Health Assessment Flashcards | StudBud