4410 Class 1

What is the medical record?

a record keeping of pertinent facts that is a legal document

What does the medical record include?

patient’s health history, interview, general assessment, medication record, and plan of care written by healthcare professionals

Describe why the medical record is a legal document

It is evidence of all care that was given and falsification results in legal action. Not documented, not done

Who is the medical record used by?

Used by third-party payers for verification and reimbursement (Medicare, Medicaid, private insurance companies)

What are the two formats of the medical record?

paper chart and electronic medical record (EMR)

What are the advantages of the EMR over the paper chart?

more accurate, more up to date, legible, easy access, timely

Which software contain the EMR?

IHIS and OSU Mychart

What does the patient’s medical record contain?

chief complaint (CC)

history of patient illness (HOPI)

past medical history (PMH)

family history

social and environmental history

review of systems

What is chief complaint?

Why the patient is seeking medical attention and in the patient’s own words (from patient)

What is history of present illness (HOPI)?

chronological description of each symptom (subjective). Includes the onset, frequency, type, duration, location, severity and aggravating/alleviating factors

What is included in Past Medical History (PMH)?

other health problems

previous hospitalizations

previous injuries or operations

allergies

immunizations

habits (smoking, drinking, drugs including vaping)

medications (dosage, frequency, route)

childhood disease

Give two examples of how PMH affects care plan

Patients in alcohol withdrawal have different respiratory needs since they are febrile, sweaty and vomiting which poses a higher risk of aspiration. Patients who take fentanyl or similar drugs may need a higher dose for sedation.

What is included in the family history?

family history (alive, dead, when?)

family disease/disorder history

family relationships and support, marital status

Give an example of family history

Parents died in their 80s; lives with wife and grandson

What is included in the social and environmental history?

occupational history

recent travel

hobbies

educational level (important when giving instructions to patient)

living arrangements

What is included in the review of systems?

system by system report of the physical exam

What is the typical format for recording the physical examination?

1. initial impression - age, height, weight, sensorium, and general appearance

2. vital signs - pulse rate, respiratory rate, temperature, and blood pressure

3. head, ears, eyes, nose, and throat - inspection findings

4. neck - inspection and palpation findings

5. thorax - lungs: inspection, palpation, percussion, and auscultation findings, heart: inspection, palpation and auscultation findings

6. abdomen - inspection, palpation, percussion, and auscultation findings

7. extremities - inspection and palpation findings

What is communication?

the activity of conveying meaningful information

What is the 5 basic components of communication?

sender, message, channel, receiver, feedback

Who is the sender?

you / the patient

What is the message?

what is to be conveyed

What is the channel?

your approach to delivering the message - seeing, hearing, smelling, touching, tasting

Who is the receiver?

you/ the patient

what is feedback?

dialogues between sender and receiver (2-way process)

What are some factors of communication?

1. internal factors (values, culture, belief, feelings)

2. sensory/emotional factors (anxiety, pain, mental acuity)

3. environmental factors (light, noise, distance)

4. verbal expression (language barrier, tone)

5. nonverbal expression (facial expression, body movement)

What is the purpose of patient interview?

1. establish clinician-patient rapport - establish a connection

2. obtain essential information - why patient needs treatment, CC, signs and symptoms, comprehensive health history

3. monitor changes in patient’s symptoms - response to therapy

What are some guidelines for effective patient interviewing?

1. Establish your professional role

2. Provide undivided attention

3. Respect your patient and their belief and rights

What is HIPAA?

Health Insurance Portability and Accountability Act. It is a federal law stating that you must protect the privacy of personal health information (PHI).

What is the sequence for conducting patient interview and general assessment?

pre-interview stage → introductory stage —> initial assessment —> general assessment —> treatment and monitoring —> follow-up

What should you do during the pre-interview stage?

1. review the patient’s medical record - locate admission note and HOPI; check orders

2. Information from other caregivers - review recent progress and nursing notes

What should you do during the introductory stage?

1. start in social space (4-12ft from patient) - identify patient and identify yourself and purpose

2. general observation - evaluate level of consciousness, if alert and oriented (patient knows time, place, person), interview can continue

What should you do during initial assessment?

Interview (patient history) - remain in patient’s personal space (2-4ft), make eye contact and maybe pull up a chair, then start asking neutral, open-ended questions

What should you do during general assessment?

remain in intimate space (0-2ft) from patient and conduct vital signs, signs and symptoms assessment

What should you do during treatment and monitoring?

Give treatment and determine effects and complications

How should you follow-up?

Patient outcome/benefits, patient feedback, your recommendations

How should you start your general assessment?

with vital signs

How many places can you take temperature?

tympanic, axillary (underestimates), core (most accurate), oral

Where can you obtain core temperature?

Rectal, pulmonary artery or urinary catheter

What is the normal range of temperature of adults?

96.0F - 99.5F (35.5 - 37.5 C)

What is the normal range of temperature for children?

97.0 - 99.9F (36.1 -37.7C)

What is hypothermia?

abnormally low body temperature < 35 C

What is hyperthermia?

abnormally high body temperature > 37 C

How to convert F to C?

F = (C x 9/5) + 32

How to convert C to F?

C = (F - 32) x 5/9

How many F is 37 C?

98.6F

How many C is 102 F?

38.9 C

What is the normal HR for adults?

60-100 bpm (80 bpm)

What is the normal heart rate for children?

90-120 bpm

What is bradycardia?

abnormally low heart rate < 60 bpm

What is tachycardia?

abnormally high heart rate > 100 bpm

Where can you obtain heart rate?

radial artery, brachial artery, femoral artery, carotid artery, pedal artery

What is the normal RR for adults?

12-18 bpm

What is the normal RR for children?

20-40 bpm

What is bradypnea?

abnormally low RR < 10 bpm

What is tachypnea?

abnormally high RR > 20 bpm

How to obtain RR?

Counted while watching the chest wall or abdomen move in or out, while listening to breath sounds

What is BP?

measurement of pressure within the arterial system

What are the two BP?

systolic pressure: ventricles contract, diastolic pressure: ventricles relax

What is the normal BP for adults?

(90-140) / (60-90) mmHg (120/80 mmHg)

What is hypertension?

abnormally high blood pressure > 140/90 mmHg

What is the risk for hypertension?

heart attack or stroke

What is hypotension?

abnormally low blood pressure - systolic < 90 mmHg

What device is used to measure blood pressure?

sphygmomanometer aka BP cuff

What does pulse oximetry measure?

indirectly measures arterial oxyhemoglobin saturation (SpO2)

What is the normal pulse ox?

93-100%

What should you do after taking vital signs?

Conduct a general pulmonary assessment

What is dyspnea?

difficulty breathing or SOB

Which patients is dyspnea common in?

patients with pulmonary or cardiac disease

How can dyspnea vary?

activity, time of day, medication adherence, emotional state

How to determine details of dyspnea in patient interview?

ask specific questions and can use standard scale to be more specific (e.g. Borg 1-10)

What is orthopnea?

difficulty breathing while lying down

Which patients is orthopnea common in?

CHF, diaphragmatic paralysis, obstructive sleep apnea, COPD, asthma exacerbations

What is platypnea?

difficulty breathing while erect/upright

Which patients is platypnea common in?

arteriovenous malformation in lung, chronic liver disease

What is chest auscultation?

listening to breath sounds

What is cough?

forceful expiratory maneuver which expels mucus and irritants from the airway

Where does coughing arise from?

arises from receptors in pharynx, larynx, trachea and larger bronchi

What is cough influenced by?

inflammation, mucus and foreign materials

What should you look out for in cough assessment?

1. effective or ineffective (no need to have sputum, can be to clear throat)

2. strong or weak

3. acute or chronic

4. productive or non-productive (produce sputum)

What is hemoptysis?

coughing up blood or blood streaked sputum

Which patients are hemoptysis common in?

lung cancer

tuberculosis

airway trauma

pulmonary embolism

bronchiectasis

lung abscess

What are the two types of chest pain?

pleuritic and non-pleuritic, acute or chronic (have to ask)

What is pleuritic chest pain?

hurts when you take a deep breath

Where is pleuritic chest pains usually happening?

posterior or lateral

How does pleuritic chest pain feel like?

sharp or stabbing

What causes pleuritic chest pains?

pleural lining inflammation, pneumonia, pulmonary embolism

What is non-pleuritic chest pains?

radiating to back or shoulder

Where is non-pleuritic chest pains?

anterior or central

How does non-pleuritic chest pains feel like?

dull or pressure-like

What causes non-pleuritic chest pains?

angina, GERD, esophageal spasm