1. Record and Report Patient Data PP3
3.01 Understand Diagnostic and Therapeutic Services

2. 3.01 Understand Diagnostic and Therapeutic Services
Record Patient Data
Pt data must be recorded accurately.
Document procedures as you do them.
Use the proper format and appropriate forms.
Record results in BLACK ink.
3.01 Understand Diagnostic and Therapeutic Services

3. 3.01 Understand Diagnostic and Therapeutic Services
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 pt and is not recognizable
to anyone else
3.01 Understand Diagnostic and Therapeutic Services

4. 3.01 Understand Diagnostic and Therapeutic Services
SOAP Notes
Subjective observations: what the patient states (symptoms)
Objective observations: what is seen or measured (signs)
Assessment: normal versus abnormal
Plan: what will be done
3.01 Understand Diagnostic and Therapeutic Services

5. Subjective observations:
what the pt states (symptoms)
“My tooth hurts.”
“My jaw aches.”
“I bit my tongue.”
3.01 Understand Diagnostic and Therapeutic Services

6. Objective observations:
what is seen or measured (signs)
temperature
color
blood pressure
amount or size
location
3.01 Understand Diagnostic and Therapeutic Services

7. Assessment: normal versus abnormal
3.01 Understand Diagnostic and Therapeutic Services

8. 3.01 Understand Diagnostic and Therapeutic Services
Plan
what will be done?
3.01 Understand Diagnostic and Therapeutic Services

9. Record Patient Data SOAP Notes
Subjective observations: what the patient states (symptoms)
Objective observations: what is seen or measured (signs)
Assessment: normal versus abnormal
Plan: what will be done
3.01 Understand Diagnostic and Therapeutic Services

10. Application Subjective or objective?
3.01 Understand Diagnostic and Therapeutic Services

11. Subjective or objective?
3.01 Understand Diagnostic and Therapeutic Services

12. Subjective or objective?
3.01 Understand Diagnostic and Therapeutic Services

13. Subjective or objective?
3.01 Understand Diagnostic and Therapeutic Services

14. Subjective or objective?A B
3.01 Understand Diagnostic and Therapeutic Services

15. How would you record the following statement?
The patient is having a seizure.
3.01 Understand Diagnostic and Therapeutic Services

16. How would you record the following statement?
The patient is nervous.
3.01 Understand Diagnostic and Therapeutic Services

17. How would you record the following statement?
The patient has dermatitis.
3.01 Understand Diagnostic and Therapeutic Services

18. How would you record the following statement?
The patient is cyanotic.
3.01 Understand Diagnostic and Therapeutic Services

19. 3.01 Understand Diagnostic and Therapeutic Services
Report Patient Data
3.01 Understand Diagnostic and Therapeutic Services

20. 3.01 Understand Diagnostic and Therapeutic Services
Oral reports:
Report observations, patient results or requests to
supervisor/staff prior to leaving the area.
Report abnormal results to supervisor immediately.
Team reports
Individual reports
3.01 Understand Diagnostic and Therapeutic Services

21. 3.01 Understand Diagnostic and Therapeutic Services
Written reports:
Test results or observations are relayed on the pt’s medical record
The medical record is a legal document.
Information must be accurate
3.01 Understand Diagnostic and Therapeutic Services

22. Summary: Collect, Record, Report Patient Data
Choose appropriate tool to assess pt’s tx plan
Analyze information gathered
Evaluate pt response to tx and/or procedure
Revise tx plan based on info. gathered
Record and report accurately, in a timely manner
3.01 Understand Diagnostic and Therapeutic Services