Collect Patient Data 3.01 Understand Diagnostic and Therapeutic Services 1

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 patients chart to anticipate patient needs 2

Collect Patient Data Patient Interview Demographic data –Patients 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 3

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 4

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 –Facilitys practices related to privacy –Where and how to file a complaint Receipt of information must be signed by patient Understand Diagnostic and Therapeutic Services 5

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 patients request 3.01 Understand Diagnostic and Therapeutic Services 6

Collect Patient Data Patient Interview Medical history –Chief complaint –Present illness –Medical history –Family history –Social history –Review of systems 3.01 Understand Diagnostic and Therapeutic Services 7

Collect Patient Data Patient Interview Obtain Medical History Activity 3.01 Understand Diagnostic and Therapeutic Services 8

Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services 9

Collect Patient Data Patient Assessment 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 10

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment 11

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment 12

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) 13

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment See (observe) See (observe) What do you see? 14

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment SMELL SMELL What do you smell? unusual odors –body –breath –wounds –body fluids 15

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment TOUCH 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 16

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. 17

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment HEAR What do you hear? body sounds speech breathing laughter/crying Auscultation- listening to internal body sounds, usually with a stethoscope

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment 19 Activity

Collect Patient Data Patient Assessment

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment Ophthalmoscope used to examine the eyes 21

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment Otoscope used to examine the ears 22

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment Penlight used to determine pupil size/reaction 23

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment Reflexhammer used to test reflexes 24

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment Scales used to measure weight Wheelchair scale Mechanical lift with a scale Balance-beam scale Baby scale 25

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment Sphygmomanometer used to measure blood pressure 26

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment Stethoscope used to listen to internal body sounds 27

3.01 Understand Diagnostic and Therapeutic Services Collect Patient Data Patient Assessment Non-mercury glass thermometer Electronic thermometer Aural thermometer Thermometer used to measure heat Digital thermometer 28

Collect Patient Data Patient Assessment Activity