PATIENT ASSESSMENT, AN ESSENTIAL SKILL

Patient Assessment: Essential Skills for Radiographers

• Observation, assessment, and evaluation are everyday critical thinking skills that clinicians use intuitively, and when practiced consciously in radiography, they increase professional value and sensitivity to patients’ conditions.

• Patient assessment is essential for anyone caring for ill or injured patients; in imaging, the radiographer may be the only person to recognize needs for medical response.

• Proper assessment helps with prioritization, room scheduling, and sequencing of patients, particularly when patients are acutely ill, in pain, or in emergencies.

• Radiographers relay information to radiologists by taking a relevant history and noting pertinent observations to aid diagnosis and treatment decisions.

Taking a History

• Radiologists rely on radiographers to collect accurate history and current condition information.

• The history influenced exam conduct and helps focus interpretation to meet the referring physician’s needs.

• It is not a detailed medical history; it explains why a particular radiographic study is performed (e.g., site of injury).

• Taking a history is an opportunity to give the patient individual attention and build rapport, which affects the amount of information obtained.

• Introduce yourself, address the patient by name, and address immediate concerns promptly.

• Many facilities use the AIDET communication tool to facilitate patient-caregiver communication:

  • Acknowledge: Warm greeting by name

  • Introduce: State your name, title, and time in the profession; explain what you will do

  • Duration: Explain how long the exam will take; update on delays

  • Explanation: Describe the examination and collect pertinent history

  • Thanks: Express gratitude for choosing the facility and for the patient’s cooperation

Questioning Techniques (to improve data-gathering)

• Use a structured set of techniques to encourage communication and keep the patient on topic:

  • Open-ended questions

  • Facilitation

  • Silence

  • Reflection or reiteration

  • Clarification or probing

  • Summarization

• Start histories with open-ended questions to invite narrative about the condition and imaging rationale; follow with closed questions to fill gaps.

• Nod or say

  • “yes”
    to encourage continued patient storytelling.

• Silence gives patients time to think; use reflection to restate what the patient has said to verify accuracy.

• Probing questions should use terminology understandable to the patient and seek specific details (e.g., exact location of pain).

• When all information is gathered, summarize the history to confirm key points and ask if there is anything else the patient forgot to mention.

Elements of a History

• Begin with general questions about the problem (e.g., "Do you know why Dr. Chen wants you to have an x-ray image of your chest?") and build on the imaging order by probing for more details.

• Some orders lack rationale; departments may require additional information; in practice, the only recorded information is often admitting diagnosis, which may seem irrelevant without explanation.

• The information you obtain should be recorded as prescribed by the institution; you may enter it directly into the EMR.

• Some examinations require very specific histories; the exact information varies among radiologists (e.g., if intravenous iodine contrast is used, allergy history and renal function data are essential).

• Patients may complete a pre-study questionnaire; Table 13.1 provides commonly useful questions and observations for various complaints.

• For chronic conditions or post-treatment follow-up, comparison with prior examinations may be required; include prior relevant exams, dates, and locations, and mention other tests if relevant (lab tests, ultrasounds, etc.).

Format for Chief Complaint and Data Collection

• A standard outline helps elicit data efficiently and reduce missed information:

  • Onset: How did it start? What happened? When did it first trouble you? Was it sudden or gradual?

  • Duration/chronology: Have you had it before? Is it continuous? Is it constant?

  • Specific location: Where does it hurt? Can you pinpoint the pain?

  • Quality of symptoms: What does it feel like (sharp, stabbing, dull, throbbing)?

  • Severity: How severe is the pain? Use a pain scale (0 to 10; 0 means no pain, 10 means the worst imaginable pain) 0 ext{ to } 10

  • Aggravating/alleviating factors: What worsens or improves the pain? Time of day, meals, rest, position changes?

  • Associated manifestations: Are there other related symptoms?

• The history should be framed to be realistic and considerate; avoid blunt questions about sensitive topics (e.g., cancer) by addressing the issue generally rather than with direct, blunt questions.

• Example of a non-threatening opening: "Do you know why your doctor ordered this examination?" instead of directly asking about cancer.

• History-taking improves with practice; role-play with peers can enhance sensitivity and confidence.

Assessing Current Physical Status

• Baseline observation is critical: establish a baseline to detect changes during and after procedures.

• Radiographers often observe significant changes first; consistent monitoring improves patient safety.

• Checking the chart before the procedure is essential:

  • Review physician orders for completeness and specificity; verify the order in the EMR after the patient is registered.

  • Note admitting diagnosis and the most recent progress notes.

  • Use the EMR or hospital information system to verify preparations and prior data.

• Nursing notes can be helpful (e.g., mobility status, ability to void, vomiting, etc.).

• Allergies are often highlighted at the top of the EMR; color-coded bracelets may indicate allergy status, fall risk, or do-not-resuscitate status.

• Allergic patients are more likely to have adverse reactions to contrast media; report a complete allergy history to the radiologist for contrast administration (further allergy assessment discussed in Chapter 19).

Physical Appearance and Responses (Assessment as an Ongoing Process)

• Assessment is an ongoing process of observation, comparison, and measurement of changes in condition before, during, and after imaging procedures.

• Eyeballing: Compare the current patient to prior similar patients and to the patient’s own prior appearance to detect subtle or subliminal changes.

Skin Color and Other Physical Cues

• Skin color changes are among the easiest signs to recognize, though complexion varies among individuals.

• Pale skin and other color changes can indicate acute changes in status; continuous assessment requires noting deviations from expected baselines.

• The discussion of skin color continues beyond what is shown here (the text proceeds to further signs and observations in the next pages).

Table 13.1: Examinations, Questions, and Observations (Illustrative Summary)

• The table provides structured example questions and observations across examination areas, including:

  • Orthopedic / acute injury

  • Neck / spine

  • Head

  • Chest

  • Abdomen / gastrointestinal

  • Urology

• Examples of clinical questions include: method of injury, exact location of pain, the presence of numbness or tingling, urinary symptoms, fever, respiratory symptoms, and prior surgeries or imaging.

• Observations include: swelling, deformity, discoloration, range of motion, gait, speech clarity, and respiratory status.

• Example history entry: "Twisting injury, L ankle, while skiing today; swelling & pain over lateral malleolus." / "MVC 10/12/20; lower neck pain & L shoulder pain; numbness & tingling, L hand." / "Lifting injury 2 weeks ago." / "LBP radiating to R hip." / etc.

• Common radiography abbreviations used in the field include MVC (motor vehicle crash), HA (headache), hr (hour), L (left), LBP (lower back pain), LLQ (left lower quadrant), R (right), SOB (shortness of breath), US (ultrasound), UTI (urinary tract infection).

• See Appendix B for common abbreviations.

Practical and Ethical Implications

• Building rapport and demonstrating empathy during history-taking improves information accuracy and patient experience.

• Sensitive topics require tact and a general framing to prevent distress while eliciting needed information.

• Accurate history and current status assessment support patient safety, appropriate exam planning, and timely intervention if deterioration occurs.

• The radiographer’s role includes recognizing when patient condition changes require escalation to the radiologist or other medical staff.

Key Takeaways

• Observation, assessment, and evaluation are core thinking skills that translate directly to safer, more efficient imaging practice.

• A concise, patient-centered history explains the rationale for imaging and informs exam conduct, while questioning techniques help gather complete, accurate data.

• AIDET provides a practical communication framework to establish rapport and manage patient expectations.

• Always check and integrate information from the chart, EMR, alerts (allergies, fall risk, DNR), and prior studies to guide current practice.

• Baseline assessment and continuous observation are essential for catching early signs of deterioration during radiographic procedures.

• The material above serves as a foundational framework; consult Table 13.1 and Chapter 19 for detailed contraindications and allergy-related considerations with contrast media.

Note: The content continues beyond Skin Color in the provided transcript and may include further signs, observations, and procedural guidance in subsequent pages.