PATIENT ASSESSMENT, AN ESSENTIAL SKILL

Vocabulary flashcards covering key terms related to observation, assessment, history-taking, communication, and patient safety in radiography.

Observation

The act of noticing and noting changes in the environment or a patient’s condition; a basic critical-thinking skill used in daily life and clinical practice.

Assessment

The process of evaluating information about a patient to determine status and needs; includes recognizing adverse changes and prioritizing care.

Evaluation

The process of judging whether information and outcomes meet expectations and deciding if actions are beneficial or warranted.

Critical thinking

Systematic, reflective reasoning used to interpret information, judge its significance, and make clinical decisions.

Patient assessment

The essential skill of evaluating a patient’s current condition, needs, and potential changes to guide care.

Radiographer's role in patient assessment

The radiographer may be the first to recognize a patient’s need for medical response and must relay pertinent observations to the radiologist.

AIDET

A communication framework to facilitate patient care: Acknowledge, Introduce, Duration, Explanation, Thanks.

Open-ended questions

Questions that encourage patients to provide a narrative and detailed information about their condition.

Closed or direct questions

Yes/no questions used after the patient has described their condition to obtain missing information.

Silence

A technique that gives patients time to think and organize their thoughts before continuing.

Reflection or reiteration

Restating what the patient has said to confirm listening and accuracy.

Clarification or probing

Asking questions to elicit more information or details about the patient’s condition.

Summarization

Restating the history at the end of the interview to confirm accuracy and completeness.

History

The process of gathering information about a patient’s condition and reason for imaging, focusing on why the study is being done.

Chief complaint

The primary reason a patient seeks care; guides history and examination focus.

Onset

When the problem began or started.

Duration/chronology

Whether the problem is ongoing, how long it has persisted, and its temporal pattern.

Specific location

The exact area where the patient experiences pain or problems.

Quality of symptoms

The character of symptoms (e.g., sharp, dull, throbbing).

Severity

The intensity of symptoms, often graded on a scale (e.g., 0–10).

Aggravating factors

Conditions or activities that worsen the symptoms.

Alleviating factors

Factors or actions that relieve the symptoms.

Associated manifestations

Other symptoms that accompany the chief complaint and may be related.

EMR

Electronic Medical Record; the digital system where patient data and notes are stored.

Allergies

Known reactions to substances; important to note before procedures, especially before contrast media.

Allergic individual

A patient with a history of allergies who is at higher risk for adverse contrast reactions.

Contrast medium

Agents used to enhance image quality; often iodine-based; requires review of allergies and renal function.

Intravenous iodine contrast agent

A specific IV contrast used in radiology; assess allergy history and renal function prior to use.

Renal function

Kidney function; critical to evaluate before contrast administration to reduce risk of nephrotoxicity.

Baseline

Initial measurements or status used for comparison to detect changes over time.

Eyeballing

An experienced observational skill of comparing a patient’s current appearance with previous or similar cases to detect subtle changes.

Skin color

A readily observable sign that can indicate changes in a patient’s condition or perfusion.