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

2. 3.01 Understand Diagnostic and Therapeutic Services
Record Patient Data
Patient 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. 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

4. 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

5. 3.01 Understand Diagnostic and Therapeutic Services
Record Patient Data
"My right hip still hurts since my surgery."
Subjective observations:
what the patient states (symptoms)
“My tooth hurts.”
“My jaw aches.”
“I bit my tongue.”
"I hate this place and I want to go home."
3.01 Understand Diagnostic and Therapeutic Services

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

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

8. 3.01 Understand Diagnostic and Therapeutic Services
Record Patient Data
Plan: what will be done?
The doctor orders physical therapy for the patient. This will be documented
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. Record Patient Data Subjective or objective?
3.01 Understand Diagnostic and Therapeutic Services

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

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

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

14. Record Patient Data Subjective or objective?
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
Report Patient Data
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
Report Patient Data
Written reports:
Test results or observations are relayed on the patient’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 patient’s treatment plan
Analyze information gathered
Evaluate patient response to treatment and/or procedure
Revise treatment plan based on information gathered
Record and report accurately,
in a timely manner
3.01 Understand Diagnostic and Therapeutic Services