![Playing to Be Evil [3.01]](https://static.fdocuments.us/doc/165x107/552673544a79599d488b4ffc/playing-to-be-evil-301.jpg)
3.01 collect patient data
29
Collect Patient Data Collect Patient Data 3.01 Understand Diagnostic and Therapeutic Services 1
-
Upload
melodiekernahan -
Category
Education
-
view
94 -
download
1
description
patient data
Transcript of 3.01 collect patient data
Collect Patient DataCollect Patient Data
3.01 Understand Diagnostic and Therapeutic Services
1
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient InterviewPatient 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
2
Collect Patient DataCollect Patient DataPatient InterviewPatient Interview
Demographic dataDemographic 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
3
Collect Patient DataCollect Patient DataPatient InterviewPatient Interview
Financial information Financial information
Financial policy of the practice
–Billing
–Insurance billing
–Co-payments
–Finance charges
3.01 Understand Diagnostic and Therapeutic Services
4
Collect Patient DataCollect Patient DataPatient InterviewPatient Interview
Privacy information 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
5
Collect Patient DataCollect Patient DataPatient InterviewPatient Interview
Release of informationRelease of informationTo 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
6
Collect Patient DataCollect Patient DataPatient InterviewPatient Interview
Medical historyMedical history–Chief complaint–Present illness–Medical history–Family history–Social history–Review of systems
3.01 Understand Diagnostic and Therapeutic Services
7
Collect Patient DataCollect Patient DataPatient InterviewPatient Interview
Obtain Obtain Medical History Medical History Activity Activity
3.01 Understand Diagnostic and Therapeutic Services
8
Collect Patient DataCollect Patient Data
Patient AssessmentPatient Assessment
3.01 Understand Diagnostic and Therapeutic Services
9
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
AssessmentAssessmentObjective
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
10
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
11
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
12
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
What the health care professional can:
•See (observation)
•Smell
•Touch (palpation)
•Hear (auscultation, percussion)
13
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
See (observe) See (observe) What do you see?
14
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
SMELLSMELL What do you smell?
• unusual odors– body– breath– wounds– body fluids
15
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
TOUCHTOUCH What do you feel?• pulse• warm/cold• wet/dry• soft/firm
palpationuse the hands to determinesize, shape, location, andfirmness of the internal organs
16
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient 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.
17
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
HEAR What do you hear?
• body sounds• speech• breathing• laughter/crying
Auscultation- listening to internal body sounds, usually with a stethoscope
1
2
3
4 18
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
19
ActivityActivity
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
OphthalmoscopeOphthalmoscopeused to examine the eyes
21
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
OtoscopeOtoscopeused to examine the ears
22
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
PenlightPenlightused to determine pupil
size/reaction
23
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
ReflexReflex
hammerhammer
used to test reflexes
24
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
ScalesScalesused to measure weight
Wheelchair scale
Mechanical lift with
a scale
Balance-beam scale
Baby scale 25
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
SphygmomanometerSphygmomanometerused to measure blood pressure
26
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
StethoscopeStethoscopeused to listen to internal body sounds
27
3.01 Understand Diagnostic and Therapeutic Services
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
Non-mercury glass thermometer
Electronic thermometerAural thermometer
Thermometer Thermometer used to measure heat
Digital thermometer
28
Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
ActivityActivity
