1. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Pearson's Comprehensive Medical Assisting Administrative and Clinical Competencies Second Edition CHAPTERCHAPTER CHAPTER 35 Vital Signs Lesson 1: Documentation of Patient Information

2. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Think! When an error is entered into a patient’s chart, how should this error be corrected? What might be some dos and don’t in this situation?

3. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Reasons for Maintaining the Patient Record Planning patient care Auditing health agencies for quality assurance information Gathering research data Educating future health care providers Obtaining reimbursement for services Providing legal documentation of care Analyzing health care to assist in planning for future health care needs

4. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Contents of the Patient Medical Record Intake or registration information Medical history Test results Records from other physicians or facilities Diagnosis and detailed treatment plan Operative reports Informed consent forms Hospital discharge summary Correspondence

5. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Types of Diagnoses Final or medical diagnosis –Arrived at after all tests, procedures, and examinations are complete Clinical diagnosis or working diagnosis –A preliminary presumptive diagnosis made by the physician based on the health history and physical examination Differential diagnosis –The determination of which one of several diseases is the cause of a problem

6. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Steps Needed to Gather Information for Proper Charting Before a patient has a physical examination or is seen by the physician, a medical history must be obtained The initial patient interview is conducted by the medical assistant and the information gathered becomes part of the permanent medical history After the initial data have been gathered, the patient’s vital signs, height, and weight are assessed The physician then examines the patient and records the information obtained

7. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan The Initial Patient Interview Performed to obtain information on the patient’s current and past illnesses and treatments Important to ensure the patient's privacy during the interview Patient should be made to feel at ease Appropriate types of questions should be utilized to obtain needed information

8. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Step 1: Review patient’s chart before the interview. Step 2: Greet patient by name and provide your name. Step 3: Be professional at all times. Step 4: Ask the patient’s permission to interview him/her. Step 5: Use an “icebreaker” comment to put patient at ease. Step 6: Provide privacy during the interview. Steps in Interviewing a Patient

9. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Step 7: Be aware of verbal and nonverbal cues. Step 8: Avoid making judgmental responses. Step 9: Avoid providing medical assurances. Step 10: Treat sensitive topics with respect. Step 11: Summarize important points. Step 12: Document according to facility policy. Steps in Interviewing a Patient

10. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Charting Guidelines Date and time every entry (while timing may not be required in the medical office, it is in hospital and ambulatory care settings) Write legibly Use permanent dark ink Use medical terminology and accepted abbreviations Use correct spelling Sign every entry

11. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Charting Guidelines Accurately document information (stick to facts not opinion) Document the proper sequence in which events occurred Document appropriate information concerning health and care given Be concise Correct errors only by drawing a single line through the incorrect entry and initialing it – Then record the corrected entry

12. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Correcting a Charting Error

13. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Six Cs of Charting Client’s own words used exactly and in quotes Clarity must be achieved when recording information Completeness is essential Conciseness of entries saves time and chart space Chronological order of information is critical Confidentiality of patient information is mandatory

14. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Measuring Weight and Height Called anthropometric measurements Can provide important information related to the patient’s general health Frequent weight monitoring is particularly important for: –Diabetic patients –Pregnant women –Cardiac patients –Patients with eating disorders

15. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Obtaining a Patient’s Weight Important to provide patient privacy Typically done with clothing on Shoes should be removed May need to convert information from pounds to kilograms or kilograms to pounds Patients who cannot stand may be weighed on a chair or bed scale

16. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan To Convert Kilograms to Pounds (kg to lb) 1 kilogram (kg) = 2.2 pounds (lbs) Multiply the number of kilograms by 2.2 lbs. Example: If a patient weighs 64 kilograms, Example: If a patient weighs 64 kilograms, Multiply 64 by 2.2. 64 X 2.2 = 140.8 or 141 pounds To Convert Kilograms to Pounds (kg to lb) 1 kilogram (kg) = 2.2 pounds (lbs) Multiply the number of kilograms by 2.2 lbs. Example: If a patient weighs 64 kilograms, Example: If a patient weighs 64 kilograms, Multiply 64 by 2.2. 64 X 2.2 = 140.8 or 141 pounds Converting Kilograms to Pounds

17. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan To Convert Pounds to Kilograms (lb to kg) 1 pound = 0.45 kilograms Multiply the number of pounds by 0.45. Example: If a patient weighs 130 pounds, Example: If a patient weighs 130 pounds, multiply 130 by 0.45. 130 X 0.45 = 58.5 or 59 kilograms To Convert Pounds to Kilograms (lb to kg) 1 pound = 0.45 kilograms Multiply the number of pounds by 0.45. Example: If a patient weighs 130 pounds, Example: If a patient weighs 130 pounds, multiply 130 by 0.45. 130 X 0.45 = 58.5 or 59 kilograms Converting Pounds to Kilograms

18. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Measuring a Patient’s Height Measured without shoes Heel, buttocks, and back of head should be touching the measuring stick or bar L-shaped arm is raised or lowered to rest on top of head Height can be recorded in inches and feet or centimeters –Convert inches and feet to centimeters by multiplying by 2.5 –Convert from centimeters to inches by dividing by 2.5

19. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Questions?