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1 be cautious about recording patients attitude style

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Unformatted text preview: n the chart as errors are hard to eradicate. Personal information : 1. Be cautious about recording patient’s attitude, style, expectations, or health belief system. 2. Delete info about explicit sexual habits, problematic relationship, and criminal records. I magine the chart being read by patient to determine what to write. Use caution. 3. Include patient’s own words when possible. 4. Minimize distortion by avoiding language that turns people, experiences, or feelings into pathologies. Avoid words like apathy, anxiety, denial, depression, & manipulative. Use instead determined, discouraged, hopeful, optimistic, brave, fearful, sad, or hopeless. 5. Use behavioral or functional descriptions to convey personal info (ex. what patient does during the day, hobbies) 4 functions of the clinical record Format of clinical record Problem-Oriented Medical Records (POMR) 1. Memory aid 2. Communication 3. Quality assessment and research 4. Administrative and legal matters Subjective: history (identifying data, C, HPI, OAP, PMH, FH, patient profile, review of s ystems Objective: PE, lab results Assessment: problem list Plan 1. Database that includes written history, PE, and lab data 2. A Problem list that displays the names of all identified problems, not simply diagnoses; includes both active & inactive problems; updated regularly 3. A standard format for writing about each problem (SOAP notes) 4. Devices such as flow sheets to simplify, organize, and display data CHAPTER 7: MOTIVATIONAL INTERVIEWING Lecture: Motivational Interviewing Thursday, September 08, 2005 What is motivational interviewing? Builds on perspective and skills of patient-centered interviewing. Based on Stages of Change model of health behavior change Two goals: Patient feels heard and understood. Patient is better prepared to move to next s tage of change. Describe 5 levels of empathic Additive: “I wonder if you feel like giving up?” statements that could be made to Interchangeable/synonym: “ You feel like nothing works?” the statement, "I’ve tried Reflective: “You’re frustrated?” everything and I’m frustrated: I Ignoring or minimizing: “I understand” (patient doesn’t believe you do) just can’t lose weight.” Criticizing: “You just need more discipline.” T ranst heoret ical model Based on partnership: physician expertise in medical sphere, patient in his/her life world Healt h belief model Individual changes behavior when: has sense of susceptibility links behavioral change with change in outcome cue to action behavior more likely to be sustained when it is autonomous 1. Precontemplation 2. Contemplation 3. Preparation 4. Determination 5. Action 6. Maintenance 7. Relapse 8. Termination Mnemonic for empathic reflective listening: What’s Bothering you? or Background (What's going on in your life?) How does that Affect you? How does that Trouble you? How are you Handling that? Provide Empathy T heory of self det erminat ion 8 St ages of Change BAT H...
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