3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Interview Completed on admission to a health care facility In-patient facility Outpatient facility Prepare for the patient: Room is neat Supplies are available Review the patient’s chart to anticipate patient needs 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Interview Demographic data Patient’s full name Address Mailing address, if different Telephone number home work Date of birth Social security number Insurance information Emergency contact person 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Interview Financial information Financial policy of the practice Billing Insurance billing Co-payments Finance charges 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Interview Privacy information HIPPA - Privacy rule limiting the release of patient information Information given to patient must include: Statement of patient rights Facility’s practices related to privacy Where and how to file a complaint Receipt of information must be signed by patient. 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Interview Release of information To request information from previous providers to obtain past medical records To allow sharing of information with family members at patient’s request 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Interview Medical history Chief complaint Present illness Family history Social history Review of systems 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Interview Obtain Medical History Activity 3.01 Understand Diagnostic and Therapeutic Services

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Objective Measurable vital signs weight and height test results Disease symptoms that can be observed by somebody other than the person who is ill Subjective perceived to exist only by the patient and is not recognizable to anyone else 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Using the Senses 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Using the Senses What do you see? 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment What the health care professional can: See (observation) Smell Touch (palpation) Hear (auscultation, percussion) 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment See (observe) What do you see? 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment SMELL What do you smell? unusual odors body breath wounds body fluids 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment TOUCH What do you feel? pulse warm/cold wet/dry soft/firm palpation use the hands to determine size, shape, location, and firmness of the internal organs 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Percussion – method of tapping on body areas to determine the shape, size, and/or density of underlying structures. Used to assess the chest or abdomen. Requires skill in touch and listening to the nature of the sound. 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Using medical instruments

Collect Patient Data Patient Assessment Using medical instruments Ophthalmoscope used to examine the eyes 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Using medical instruments Otoscope used to examine the ears 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Using medical instruments Penlight used to determine pupil size/reaction 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Using medical instruments Reflex hammer used to test reflexes 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Using medical instruments Scales used to measure weight Balance-beam scale Wheelchair scale Mechanical lift with a scale Baby scale 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Using medical instruments Sphygmomanometer used to measure blood pressure 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Using medical instruments Stethoscope used to listen to internal body sounds 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Using medical instruments Thermometer used to measure heat Non-mercury glass thermometer Aural thermometer Digital thermometer Electronic thermometer 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment Using medical instruments Activity