unit 2-patient interactions and documentation

charting

form of communication done by the treatment team about the patient

charting purposes

• communication from 1 team member to another

• protect patient from duplication and errors

• historical record keeping

• protect healthcare worker from litigation

• research accreditation

rules of documentation

legal info must be:

• accurate,

• spelled correctly,

• concise,

• complete,

• factual,

• well organized

can cause legal problems

general guidelines of charting

• chart is property of institution/agency

• documentation is performed according to institution guidelines

• rule of thumb: if it wasn’t charted, it wasn’t done

charting rules

• correct patient/chart/computer screen

• proper spelling and grammar

• military time

• approved abbrevations

• document properly

• if written: black/blue ink, neat and legible

• signature for every entry

• need to identify who wrote what

do’s and do not’s for charting

• Do your own charting. Never ask someone else to document for you.

• Do not document for someone else.

• Never document “ahead of time”.

• Clearly identify other staff involved in a situation.

Errors in documentation need to be corrected by the person who made the error,

• Draw a single line through the error

• Write “mistaken entry” next to the information

• Document the correct information

• Sign and date the correction

advantages of electronic charting

• Increases the quality of documentation

• Saves time

• Increases legibility and accuracy

• Links various sources of patient information

disadvantages of electronic charting

• Infringement on patient’s information

• Risk of information being offline and unavailable

• Expensive

• Extending training periods

Parts of the Patient Chart/ Documentation Important to the RT

• History and Physical (H&P)

• Physician/Nurse Practitioner Orders

• Hall Pass/ SBAR

• Informed Consent

• Advance Directive

• Radiology Procedure Report

History and physical examination(H&P)

• gives general background of patient’s condition and reason for admission

• NOTE: Only tells condition at time of admission (not necessarily current – would need to use other sources

progress notes

find out what has happened since time of admission

who can write an order?

doctor/ physician (MD/DO)

medical resident

nurse practitioner

RNs and PA

• if ordering physician is not the same person who has entered order, it must be authorized by MD

orders requirements

• Specific orders for each procedure must be in the chart before a procedure is done

  - An order is good for 14 months at RH

• RT must check to verify that the order exists BEFORE performing the study

• Verbal orders (MD calls in an order - must include MD name and co-signed by an RN before an exam can be done)

  - Good for 24hours

  - May not perform “recommended” orders if MD has not signed off

• Orders for portable exams must clearly state “portable

hall pass/ hand off communication/ SBAR

• Used to provide accurate information about a patient’s care, treatment or service when responsibilities are “handed off” from one care provider to another

• Patient’s hall pass (and chart if applicable) needs to accompany her/him wherever she/he goes in the hospital

• Ensures continuity and safety of the patient’s care

hall pass/ hand off communication/ SBAR requirements

• Should include the patient’s name, date and time

• Lists the name and phone number of caregiver (nurse)

• Person receiving chart needs to validate hall pass

- Initials

-Department

-Time

SBAR

situation

background

assessment/observation

recommendation

situation in SBAR

 What is going on with the patient?

• DNR status (Allow Natural Death)

• Patient’s destination

• Patient has multiple tests ordered

 Current medical and/or nursing concerns

background in (SBAR)

Recent changes in condition or treatment What is the clinical background or context?

 Isolation status and reason for isolation

 Patient is a fall risk

 Allergies

 Patient recently received pain medication

 Patient has recently had a change in level of consciousness

 Patient speaks only Spanish and will need an interpreter

assessment in SBAR

• Anticipated changes in condition

• What do I think the problem is?

- Current assessment trends

- Current responses to treatment

ex: Patient is drowsy after receiving pain medication

another one:

- Patient receiving oxygen therapy

- Patient receiving IV fluids

- Patient’s mobility

 Self

 Assist 1

 Assist 2

 Total Assist

- Weight bearing restrictions

- Patient is NPO

recommendation in SBAR

What to watch for

What would I do to correct the problem?

• information for follow-up

• Post procedure needs

• Patient is diabetic and has been NPO for exam; watch for signs of decreased blood sugar

• Please give discharge instructions to spouse since patient is confused

consent

Any invasive procedure requires written/informed consent

ex: myelogram and arthrogram

must be signed by patient, a witness, and the doctor performing the procedure

universal protocol

A standard procedure with multiple checks utilized within the admission/assessment process to minimize the risk of wrong site, wrong procedure and wrong patient surgery.

HIPPA • Health Insurance Portability and Accountability Act (1996)

• Improve efficiency and effectiveness of the health care system by mandating confidentiality of health information

• Ensures privacy, security, and the establishment of standards and requirements for the electronic transmission of certain health information

• Governs access and usage of patient-identifiable info

• Ethical standard

• HIPAA violations may result in disciplinary actions

• ALWAYS applies

• shared ONLY for healthcare providers for purpose of medical treatment

body mechanics

Moving, lifting, positioning and handling patients and equipment safely is known as body mechanics

biomechanics

• Examines the action of forces on bodies at rest or in motion

• Fundamental to good patient handling techniques – concepts of base of support, center of gravity and mobility and stability muscles

understanding basics of biomechanics

• Help prevent back injury

• Promote safe and effective:

• patient transfer

• position

base of support

Foundation which the body rests

• Standing – the feet and the space between the feet

• Feet far apart = larger base of support = better support

• When transferring a patient, you need a stable base of support

center of gravity

Hypothetical point at which all the mass appears to be concentrated

Anatomic position –Sacral level two

Stability is achieved when

the body’s center of gravity is over its base of support

Instability occurs when

the center of gravity is beyond the boundaries of the base

Mobility Muscles

found in limbs = use for lifting

• Bicep, hamstring

Stability Muscles

found in torso = use for support

• Provide postural support

• Rectus abdominis – support abdomen

Lifting should be done by

bending and straightening knees and the back should be kept straight or slight lumbar lordosis

assessing patient’s mobility

Always ask the patient if they can independently do the transfer

Let patients do as much as possible

Check the chart

Weight bearing restrictions, - FALL RISK

Be protective with certain diagnoses- Pelvic girdle fracture, dementia

Inform the patient of what you are doing and list your steps out

rules for safe patient transfer

Stand with feet apart

Patient’s center of gravity should be held close to transferee's center of gravity

Use transfer belt if available

Keep back stationary and let legs do the lifting

NO TWISTING, pivot

orthostatic hypotension

Dizziness, fainting, blurred vision and slurred speech

Patient should stand slowly

Talk throughout transfer

positioning for safety, comfort or exams

Ensuring patient is safe on table, bedrails up when applicable, safe from harm of other equipment in room. Not causing more injury to patient with positioning.

Ensure patient is comfortable as possible throughout exam; use head pillow if possible, x-ray mat on table

Positioning properly based on department protocols, ALARA, low repeat rate

patients who have fall risk

• Yellow wrist band

• Spinning top symbol

• Documentation of assistance needs on the Hall Pass

gait belt(transfer belt)

• Device used for transferring patient and assisting with ambulation.

• Helps RT improve grip and control of the patient

• Helps prevents falls

• Should not be used on patients with abdominal or thoracic incisions

how to apply gait belt

1. Put the gait belt around the patient’s waist with the clasp in the front.

2. Thread the gait belt through the clasp and tighten the belt until snug around the patient’s body. You should only be able to slip two fingers under the belt.

wheelchair transfers

1. Standby assist

2. Assisted standing pivot

3. Two-person lift

4. Hydraulic lift

things to remember for transfer

 Before allowing a patient to stand, make sure his/her feet are properly covered for support

-Shoes

-Nonskid slippers

-Slipper socks

 Always transfer to the patient’s strong side  Brakes are locked

 Footrests removed or folded

 ALWAYS let the patient know what you’re going to do or need them to do

standby assist

• 45 degrees

Used for patients who have the ability to transfer from a wheelchair to a table on their own

•Provide movement instructions to the patient continually during transfer

assisting standing pivot transfer

• For patients who cannot transfer independently but can bear weight on their legs, a standing pivot technique is used

• Wheelchair at 45-degree angle to the table

• can use gait belt for this one

two-person lift

 Used on patients who are lightweight and cannot bear weight on their lower extremities

 Stronger person lifts the patient’s torso(person in charge), other person lifts the feet Torso lifter is the in-charge lifter

verbally plan out procedure

hydraulic lift techniques(maximove is an example)

 Used for heavy patients

 Familiarize yourself thoroughly with lift operations before using this type of lift

 Patients need to be seated on a lift sling before using this type of lift

 Sending a patient back to the floor to return sitting on a sling is better than risking injury to the patient, the transferrer, or both by attempting transfer without using a sling

 Communication is critical to lift success

lateral transfer

1. Sheet transfer(litter, gurney, or cart)

2. Three-carrier lift

3. Log roll

things to remember when moving patient

1. Try to avoid tearing the patient’s skin, especially that of elderly patients

2. Be aware of all IV tubing, oxygen tubing, urine bags - catheters and drainage devices

3. Have patient cross arms over her chest during transfer

- Reduces surface area

-Creates less friction during transfer

litters guidelines

 Position litter as close as possible to table

 Litter should be the same height as the table

 LOCK the wheels!

 Lower bed rails

 Best to have three people to move patient

 Person at the head gives direction

what kind of board can you use for transferring?

sliding board

assistive devices to transfer bariatric patients

• hovermatt

• bariatric hoist

These products help manage the growing bariatric population with both sensitivity and safety by minimizing the physical demand of lateral transfers, vertical lifting, and repositioning for routine care.

Bariatric Transfer and Equipment Accommodations

 Transfer from litter/bed to x-ray table may require a greater number of personnel, up to 8 to 10 individuals, then is specified by department policy

 Obese patients are not manually lifted, they are moved by sliding -- Such as Hovermatt or the high-capacity power lifts

 Upright images during fluoroscopy – - foot board should be removed, allowing the patient to stand directly on the floor

 Have a large study bench available in case patient becomes unstable or needs to sit

 Be knowledgeable of table weight limits

log roll

• is a technique used to turn a patient whose body must be kept in a straight alignment at all times (like a log)

• This technique is used for the patient who has a spinal injury(collar on neck)

• used for the patient who must be turned in one movement, without twisting.

• requires two people, or if the patient is large, three people.

• WE CAN NOT HOLD THE NECK

what is a fall?

 An unplanned, sudden, descent to the floor

 With or without injury

 Can be result of physiological or environmental conditions

 An assisted fall is STILL considered a fall

• Falls are the most common hospital accident

most prone to fall

Elderly

Frail

Sensory deprivation

Medicated (Sedated)

factors that contribute to falls

• Age older than 65 years

• History of falls

• Impaired vision or balance

• Altered gait or posture, impaired mobility

• Medication regimen

• Postural hypotension

• Slowed reaction time

• Confusion or disorientation

• Unfamiliar environment

prevention of falls

 Understand condition of patient (SBAR handoff)

 Keep floors clear of objects which may obstruct pathway

 Keep equipment (wheelchairs, stretchers/litters etc.) in areas where they will not obstruct passageways

 Side rails up when on litter/stretcher (Always)

 Locks on wheelchairs or litters (Always when moving patient on/off)

 Always assist patient on/off the table (Ambulatory, litter, wheelchair)

standard fall prevention interventions

 General considerations such as wear eyeglasses, non-skid slippers or shoes

 Keep call bell within reach & answer promptly

 Keep personal items within easy reach

 Keep assistive devices within easy reach if independently ambulatory

 Keep litter and wheelchair wheels in locked position

 Provide adequate lighting

 Reduce environmental clutter

how to walk in walker

Advance walker

Advance the first foot

Advance the other foot forward

Repeat cycle

Fall Prevention: Bed/Chair Exit Alarms

 Precautionary measure for patients who are at risk for falling

 Position sensor pad under shoulders (litter) & under buttocks (chair) with delay of zero

 Volume set at 10 & delay set at 0 seconds at all times

 Verify alarm is turned on each time**

 Never leave the patient alone without being certain that the green light is flashing which says the BED/CHAIR alarm is turned on

Positioning for safety, comfort or exams

 Patient should travel as a single unit

 Placed on table in a safe and secure position

 Moved segmentally into the desired body position

 Communicate

 Let patient assist as much as possible

 Always roll the patient toward you

 Provide positioning sponges to support the patient

Positions to know as a Radiologic Technologist

• supine

• fowlers

• semi-fowlers

• modified lithotomy

• trendelenburg

• SIMS

• right posterior oblique(RPO)

• left posterior oblique(LPO)

• right anterior oblique(RAO)

• left anterior oblique(LAO)

• right lateral(decubitus)

• left lateral (decubitus)

• dorsal (decubitus)

• ventral (decubitus)

supine

patient is laying horizontally on their back

prone

patient is laying horizontally on their stomach

fowlers

patient’s head is raised 18-20 inches above the flat position, knees can also bend

modified lithotomy

used for hysterosalpingogram in fluoro and in the operating room for certain procedures

trendelenburg

patient is supine on the table or bed, head is tilted downward 30-40 degrees with feet higher than the head

• used for fainting, shock, venous return

semi-fowlers

the patient is at an incline position at an angle of 30 to 45 degrees. the patient is at supine position with knees flexed

SIMS

used for enema tip insertion and rectal temps

patient bracelets

• General Information: If a bracelet is removed, a new bracelet must be applied immediately

• When applying a bracelet, the caregiver must identify the patient using two identifiers (name, DOB)

2 identifiers required

• Use at least two ways to identify patients Example: use the patient’s name and date of birth

• Ensures the patient gets the correct medicine and treatment

other acceptable identifiers

 An assigned identification number

 Telephone number

 Address

 Photograph

 Other person-specific identifiers

fall risk bracelet

yellow

allergy bracelet

red

allow natural death(AND) bracelet

purple

latex allergy bracelet

green

blood bank bracelet

orange

arm restriction bracelet

hot pink

6 types of wristband errors

• Absent wrist band

• Wrong wrist band (another patient’s wrist band)

• More than one wrist band (may contain conflicting information)

• Partially missing information

• Partial erroneous information on wrist band

• Illegible identification on wrist band

standard precautions

used to protect against acquiring pathogens we know the person has as well as those we don’t

• Minimize transfer of bacteria/pathogens

• Handwashing / hand hygiene

clinical history

• Describes the information available about the patient’s condition

• Must get pertinent information from the patient for the radiologist to properly interpret images

• Learn methods of accomplishing a valid patient interview is important as a technologist

desirable qualities in an interviewer

• respect

• genuineness

• empathy

objective

signs that can be seen, heard, felt, smelled or read on a chart

subjective

signs that can be seen, heard, felt, smelled or read on a chart

history taking

• Obtain clinical information to contribute to diagnosis process

• Explain the purpose

• Art of Healing - Communicate, explanations, take genuine interest in what the patient is saying

data collection process

ask patient to define and clarify

questioning skills

• Open-ended questions

• Facilitation (nod, umhum, “go on”)

• Silence

• Probing questions

• Repetition

• Summarization

avoiding leading questions

parts of clinical history

Chief Complaint

“Sacred Seven”

Vital signs

Pregnancy and LMP

Allergies

chief complaint

Single most important issue of the patient’s clinical history

Allows the Radiologist to focus on a specific area for diagnosis

Sometimes a patient may have more than one chief complaint

Do NOT need to obtain a complete medical history

sacred seven

LOCALIZATION

CHRONOLOGY

QUALITY

SEVERITY

ONSET

AGGRAVATING OR ALLEVIATING FACTORS ASSOCIATED MANIFESTATIONS

localization: sacred 7

• Define the exact, precise area of concern; Chief Complaint.

• May need to use touch: emphasis, palpitation

• Some pain is “non-localized” and patient may not have a complaint to a specific region

chronology: sacred 7

TIME • Duration since onset

• Frequency – not necessarily pertinent to radiology

• Course - not necessarily pertinent to radiology

Use number of days, months vs. “last Thursday”

quality: sacred 7

Character of the symptom

• Size of lumps

• Type of cough (dry, hacking, productive)

• Pain – where, type, describe, burning, throbbing, sharp, etc.

• Color, consistency of body fluids

• Presence of clots

severity: sacred 7

• intensity

• quantity

• extent

onset: sacred 7

 What were you doing when it happened?

 At night when in bed vs. with exercise? (on exertion?)

 Anything unusual happen when this first occurred?

aggravating or alleviating factors: sacred 7

what helps?

what makes it worse?

associated manifestations: sacred 7

Do other symptoms accompany the condition?

Some symptoms/illnesses or past surgeries may affect other body parts

What other things are you (RT) assessing while taking history and obtaining images?

• Condition of the patient

• Balance/mobility

• Level of Consciousness

• Range of Motion

• Pain

• Vital signs (later)

Ending the History Taking

pre-exposure instructions- Explain the positioning (“I’ll be taking several images of your neck in different positions” or explain the fluoro procedure)

length of procedure

immobilization devices

inform- sounds and movement of machine

questions

post-exposure instructions- Inform the patient about result times, next study/area to go to, barium instructions etc.