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Collect Patient Data PP2
3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Patient Interview Completed on admission to a health care facility In-patient facility Outpatient facility Prepare for the pt: Room is neat Supplies are available Review the pt’s chart to anticipate pt needs 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
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
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3.01 Understand Diagnostic and Therapeutic Services
Patient Interview Financial information Financial policy of the practice Billing Insurance billing Co-payments Finance charges 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Patient Interview Privacy information HIPPA - Privacy rule limiting the release of pt info. Information given to pt must include: Statement of pt rights Facility’s practices related to privacy Where and how to file a complaint Receipt of information must be signed by pt. 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
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
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3.01 Understand Diagnostic and Therapeutic Services
Patient Interview Medical history Chief complaint Present illness Family history Social history Review of systems 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Patient Interview Obtain Medical History Activity 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services
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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 3.01 Understand Diagnostic and Therapeutic Services
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Patient Assessment- Subjective
perceived to exist only by the patient and is not recognizable to anyone else Examples: My head hurts I feel like I’m going to throw up 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Patient Assessment Using the Senses 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Patient Assessment Using the Senses What do you see? 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
What the health care professional can: See (observation) Smell Touch (palpation) Hear (auscultation, percussion) 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Observe- See What do you see? 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
SMELL What do you smell? unusual odors body breath wounds body fluids 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
TOUCH What do you feel? pulse warm/cold wet/dry soft/firm palpation use of the hands to determine size, shape, location, and firmness of the internal organs 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
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
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3.01 Understand Diagnostic and Therapeutic Services
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
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Using medical instruments
Patient Assessment Using medical instruments
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3.01 Understand Diagnostic and Therapeutic Services
Ophthalmoscope used to examine the eyes 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Otoscope used to examine the ears 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Penlight used to determine pupil size/reaction 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Reflex hammer used to test reflexes 3.01 Understand Diagnostic and Therapeutic Services
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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
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Sphygmomanometer used to measure blood pressure (BP)
3.01 Understand Diagnostic and Therapeutic Services
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Stethoscope used to listen to internal body sounds
3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Thermometer used to measure heat Non-mercury glass thermometer Aural thermometer Digital thermometer Electronic thermometer 3.01 Understand Diagnostic and Therapeutic Services
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