Med Comm E2
Terms in this set (85)
Original
what is a problem pertinent ROS & ex
inquires about the system directly related to the problem identified in the HPI
ex:
CC = earache
ROS = + for left ear pain, denies dizziness, tinnitus, fullness, or HA
significance =
severity + duration
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ROS should include
2 above/2 below or dissecting line
what is an extended ROS
inquires about the system directly related to the problem identified in the HPI & a limited # (two to 9)
of additional systems
%
what is a complete ROS
inquires about the system directly related to the problem(s) identified in the HPI plus all additional
(min of 10) organ systems
2 basic human behaviors
safe
unsafe (fight/flight/withdrawl)
what are the 14 categories CCMS recognizes for billing purposes
General, Endocrine, HEENT, Lungs, Breast, Cardio, Abdominal, GU, Psych, Neuro, MSK
CHAPMEN-B-LGG
What is the SAFE acronym?
SAFE skills to help maintain dialogue and relationship:
S = start w/ yourself
A = assess and recognize when others are "unsafe"
F = freeze = pause to switch tracts
, STUVIA
E = engage in a dialogue = respond w/ empathy, ask about their story, apologize, tell your story,
agree on next steps
what is the S in SAFE mean
Start with yourself:
know your own hot button, understand your typical rxns, create new "stories" for more productive
relationships
what is the A in SAFE mean
A = assess others
what are the clues others are unsafe
- interruptions
- repetitions
- shouting
%
what is the F in safe mean
freeze when you recognize unsafe =
- stop everything
- "dont just do something, something, stand there"
- pause and reflect for a second
pause to switch tracts =
what is needed for safety?
can i create a story that helps me maintain dialogue and relationship?
switch tracts to rebuild safety?
what is the E in SAFE
engage in dialouge:
- ask open ended Q
- ask about their story
- respond w/ PEARLS
--P = partnership
--E = emotions
--Apology or acknowledgement
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