intro allied health final exam

medical documentaion

• communication with health care professionals

• describing patients current medical condition and history

• in addition

  • reimbursement requests

  • maintaining legal documentation

  • supporting research

communication

• primary purpose

  • provides important links between patients, professionals, and facilities

• receiving care from other professionals

• must be detailed and correct

assessment

• data

• able to compare data from visit to visit/ hospitalization to hospitalization

• can offer clues to changes in medical condition/ correct diagnosis

quality assurance

• provide evidence of quality of care a patient received

• measure the competence of professionals who provide that care

• health care audit

  • accrediting agencies might review medical documentation to determine institution meeting standards

type of medical documentation

• reimbursement

  • verify the care a patient received when a provider seeks reimbursement from insurance/ government

• legal record

  • breach of contract by the provider

  • admissible into court of law

• education

  • training/ case studies

• research

  • data

computerized documentation

• allows multiple users access to medical chart

• advantages

  • info easy access/ retrieve

  • unlimited file space

  • backup easy/ for security

  • easy to add info/ attach

  • easy to read

  • speeds information entry

cybersecurity

• sensitive patient information can be stolen by hackers who demand huge payments for the return of data

• health professionals can help prevent attacks

  • remember importance of protecting data

  • close computer programs when not in use

  • back up files

  • use strong passwords

  • never share your passwords

  • secure laptops from theft

computerized documentation

• law

  • HIPPA ( health insurance portability and accountability act of 1996)

    • regulations for the use/ disclosure of individuals health information

  • hi tech (health information technology for economic and clinical health act 2009)

    • address the privacy and security concerns associated with the electronic transmission of health info

    • strengthens the civil and criminal enforcement of HIPPA rules

characteristics of medical documentation

• accuracy

  • only facts

  • proper grammar/ spelling

  • limit errors

• completeness

• conciseness

• legibility

• organization

  • problem orientated medical record (POMR) by patients medical problems

  • source orientated medical record (SOMR) by information grouped by type

Source orientated medical record types of information

• admission sheets

• graphic/ flow sheet

• physicians orders

• progress notes

• medical HX and examination sheet

• reports

• correspondence/ miscellaneous

progress notes

• narrative notes

  • detailed written notes on all aspects of care

  • advantage

    • provider can use personal approach

  • disadvantage

    • time consuming

    • may be difficult to read and find specific information

progress notes

• SOAP notes

  • subjective (statements by PT, symptoms)

  • objective (observations/ signs, tests, vital signs)

  • assessment (diagnosis/ impression- based on subjective and objective data)

  • plan (procedures, treatments, instructions to patients)

• charting exception

  • abbreviated charting

  • more electronic charting, more common

  • note only abnormal findings

  • advantage

    • saves time

  • disadvantage

    • preventive and wellness information omitted

history and physical (H&P)

• date

• demographic data

• source of referral

• chief complaints

• history of present illness

• past history

• current health status

• family history of illness

• psychosocial history

• review of all systems

• information gathered in H&P is called the baseline

history and physical

• vital signs

  • temperature

    • fever (continuous, intermittent)

  • blood pressure

    • white coat syndrome, orthostatic (hyper/ hypotension)

    • respirations

      • SOB, shallow, tachypnea, bradypnea, cheyne-stokes

    • pulse

      • rhythm, faint, tachycardia, bradycardia

    • oxygen saturation

      • pulse oximetry

    • ADLs evaluation

AVPU scale

A= alert and aware

V= respond to verbal stimuli

P= responds to painful stimuli

U= unresponsive to any stimulus

SAMPLE history

s-symptoms

a-allergies

m-medications

p- past medical history

l- last oral intake (food/drink)

e-events leading up to illness/injury

physical examination ABC (airway, breathing, circulation)

• Head-to-Toe for Adult/Older Child

• Toe-to-Head for Infant/Young Child

• 4 Methods of Clinical Examination

4 methods of clinical observation

• inspection

• percussion

• palpatation

• ausculation

DOTS

• head examination

• deformities, open wounds, tenderness, swelling

PEARL

• eye examination

• pupils, equal, accommodation, round, light

chest examination

• dots (squeeze)

abdomen examination

• dots (squeeze)

• up to avoid punctured ribs hitting organs

secondary survey

• what you see, hear, feel

  • tapping, pale, hot/cool skin

• what the patient tells you about the illness/injury

  • nausea, back pain, no feeling

prejudice

• negative feelings about people due to race, cultural background, appearance

• also called bias

implicit bias

• bias that is outside consciousness

  • difficult to identity and overcome

• studies reveal extensive implicit bias in health care affect patient outcomes

overcoming bias

• examine responses to others

• imagine individuals as opposite stereotypes

• try to see person as an individual

defense mechanisms

• response to perceived threats to self esteem

  • provide relief from mental discomfort and anxiety

defense mechanisms ex.

• compensation

• control

• withdraw

• displacement

• acting out

• malingering

• projection

• rationalization

• regression

• repression

• denial

maslows hierachy of human needs

• abraham maslow theorized that human behavior is motivated by efforts to meet needs

maslows hiearchy in order

1. level 1 physiological; (food, shelter, and water)

2. level 2 safety and security (free from physical and psychological harm)

3. level 3 love and affection (friendships and intamacy)

4. level 4 self esteem (opinion individuals has on self)

5. level 5 self equalization (achievement of full personal potential)

hypertension

140/90

children communication

• reduce fear

• involve as possible in communication and deccision making

adults communication

• do not assume they understand everything

older adult communication

• great variation in levels of health understanding

• may need to discuss difficult age related topics

terminally ill

• may want to share feelings and concerns

• health care professionals need to come to terms with death as patient outcome

in pain, medicated,or disorientated

• identify self and say patients name

• use simple short messages

• try to schedule best time for patient

suffering from dementia

• do not confront

• use short sentences

• agree or distract patient when does not make sense

depressed

• invite patients to discuss their feelings

• allow for silence

anxious

• maintain calm

• monitor anxiety level

• stick to one topic

hearing dispaired

• ensure face and mouth of speaker are visible

• speak slowly and clearly

• turn off sources of noise

visually impaired

• announce presence and identify self

• explain procedures, sounds, and what patient can expect

• tell patient when leaving

angry

• emotional response to perceived wrong

• loss of personal control

• worries and fears

• health care professionals should not take personally

dealing with angry patients

• remain calm

• body language

• do not respond in anger

• do not argue

patient education

• patient wants information

• more self care required today

• check understanding

process for delivering patient education

1. set educational goals

2. create instructional message

3. deliver instructions

4. listen to patient questions

5. check for patient understanding

6. evaluate instructions

types of feedback

• paraphrasing

• reflecting

• asking questions

• requesting examples

communicaton process

1. set goal communication

2. create message

3. deliver message

4. listen to response

5. offer feedback

6. evaluate encounter