Collect Patient Data

1. Collect Patient Data 3.01 Understand Diagnostic and Therapeutic Services

2. Collect Patient DataPatient Interview • Completed on admission to a health care facility • In-patient facility • Outpatient facility • Prepare for the patient: • Room is neat • Supplies are available • Review the patient’s chart to anticipate patient needs 3.01 Understand Diagnostic and Therapeutic Services

3. Collect Patient DataPatient Interview Demographic data • Patient’s full name • Address • Mailing address, if different • Telephone number • home • work • Date of birth • Social security number • Insurance information • Emergency contact person 3.01 Understand Diagnostic and Therapeutic Services

4. Collect Patient DataPatient Interview Financial information Financial policy of the practice • Billing • Insurance billing • Co-payments • Finance charges 3.01 Understand Diagnostic and Therapeutic Services

5. Collect Patient DataPatient Interview Privacy information HIPPA - Privacy rule limiting the release of patient information Information given to patient must include: • Statement of patient rights • Facility’s practices related to privacy • Where and how to file a complaint Receipt of information must be signed by patient. 3.01 Understand Diagnostic and Therapeutic Services

6. Collect Patient DataPatient Interview Release of information To request information from previous providers to obtain past medical records To allow sharing of information with family members at patient’s request 3.01 Understand Diagnostic and Therapeutic Services

7. Collect Patient DataPatient Interview Medical history • Chief complaint • Present illness • Medical history • Family history • Social history • Review of systems 3.01 Understand Diagnostic and Therapeutic Services

8. Collect Patient DataPatient Interview Obtain Medical History Activity 3.01 Understand Diagnostic and Therapeutic Services

9. Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services

10. Collect Patient DataPatient Assessment Assessment Objective Measurable • vital signs • weight and height • test results Disease symptoms that can be observed by somebody other than the person who is ill Subjective perceived to exist only by the patient and is not recognizable to anyone else 3.01 Understand Diagnostic and Therapeutic Services

11. Collect Patient DataPatient Assessment Using the Senses 3.01 Understand Diagnostic and Therapeutic Services

12. Collect Patient DataPatient Assessment Using the Senses What do you see? 3.01 Understand Diagnostic and Therapeutic Services

13. Collect Patient DataPatient Assessment What the health care professional can: • See (observation) • Smell • Touch (palpation) • Hear (auscultation, percussion) 3.01 Understand Diagnostic and Therapeutic Services

14. See (observe) What do you see? Collect Patient DataPatient Assessment 3.01 Understand Diagnostic and Therapeutic Services

15. Collect Patient DataPatient Assessment SMELLWhat do you smell? • unusual odors • body • breath • wounds • body fluids 3.01 Understand Diagnostic and Therapeutic Services

16. Collect Patient DataPatient Assessment TOUCHWhat do you feel? • pulse • warm/cold • wet/dry • soft/firm palpation use the hands to determine size, shape, location, and firmness of the internal organs 3.01 Understand Diagnostic and Therapeutic Services

17. Collect Patient DataPatient Assessment • Percussion – method of tapping on body areas to determine the shape, size, and/or density of underlying structures. Used to assess the chest or abdomen. Requires skill in touch and listening to the nature of the sound. 3.01 Understand Diagnostic and Therapeutic Services

18. Collect Patient DataPatient Assessment HEAR What do you hear? • body sounds • speech • breathing • laughter/crying Auscultation- listening to internal body sounds, usually with a stethoscope 1 2 3 4 3.01 Understand Diagnostic and Therapeutic Services

19. Collect Patient DataPatient Assessment Activity 3.01 Understand Diagnostic and Therapeutic Services

21. Collect Patient DataPatient Assessment Using medical instruments Ophthalmoscope used to examine the eyes 3.01 Understand Diagnostic and Therapeutic Services

22. Collect Patient DataPatient Assessment Using medical instruments Otoscope used to examine the ears 3.01 Understand Diagnostic and Therapeutic Services

23. Collect Patient DataPatient Assessment Using medical instruments Penlight used to determine pupil size/reaction 3.01 Understand Diagnostic and Therapeutic Services

24. Collect Patient DataPatient Assessment Using medical instruments Reflex hammer used to test reflexes 3.01 Understand Diagnostic and Therapeutic Services

25. Collect Patient DataPatient Assessment Using medical instruments Scales used to measure weight Balance-beam scale Wheelchair scale Mechanical lift with a scale Baby scale 3.01 Understand Diagnostic and Therapeutic Services

26. Collect Patient DataPatient Assessment Using medical instruments Sphygmomanometer used to measure blood pressure 3.01 Understand Diagnostic and Therapeutic Services

28. Collect Patient DataPatient Assessment Using medical instruments Thermometer used to measure heat Non-mercury glass thermometer Aural thermometer Digital thermometer Electronic thermometer 3.01 Understand Diagnostic and Therapeutic Services