1. 3.01 Understand Diagnostic and Therapeutic Services
Collect Patient Data
3.01 Understand Diagnostic and Therapeutic Services

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

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

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

10. 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

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

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

13. 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

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

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

16. 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

17. 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

18. 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
1 burp
2 sound of air
3 laughter 1
4 laughter 2 1 2 3 4
3.01 Understand Diagnostic and Therapeutic Services

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

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

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

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

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

25. 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

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

27. Stethoscope Used to listen to internal body sounds

28. 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