Objective 3.01 Understanding Diagnostic and Therapeutic Services

1. Objective 3.01 Understanding Diagnostic and Therapeutic Services

2. Essential Question • What are the responsibilities of diagnostic and therapeutic services personnel? 3.01 Understand Diagnostic and Therapeutic Services

3. Diagnostic Services Diagnostic Services professionals create a picture of the health status of patients at a single point in time. Laboratory Services Laboratory Technologist Medical Technologist Imaging Services Radiologic Technologist CT/MRI 3.01 Understand Diagnostic and Therapeutic Services

4. Therapeutic Services Therapeutic Services professionals change the health status of the patient over a period of time. Physical Therapist Respiratory Therapist Radiation Therapist Dietician 3.01 Understand Diagnostic and Therapeutic Services

5. What is the difference? • What is the difference between diagnostic and therapeutic? • Diagnostic services discover what is wrong • Diagnose the patient • Therapeutic services focus on the treatment for what is diagnosed • Treat the patient 3.01 Understand Diagnostic and Therapeutic Services

6. Career Responsibilities:Diagnostic and Therapeutic Services • Plan patient care • Implement patient care • Evaluate patient care 3.01 Understand Diagnostic and Therapeutic Services

7. Career Responsibilities:Diagnostic and Therapeutic Services Plan patient care • Work within scope of practice for career area • Determine if a request is appropriate for patient • Include patient in plan of care • Develop a plan to meet patient’s needs • Assemble appropriate materials 3.01 Understand Diagnostic and Therapeutic Services

8. Career Responsibilities: Diagnostic and Therapeutic Services Implement care • Check physician’s order • Verify patient identification • Evaluate for contraindications • Obtain patient’s consent • Properly prepare patient • Perform care in an orderly manner • Perform procedure according to standards • Use equipment as recommended by manufacturer • Monitor patient’s condition throughout procedure • Modify care as required for patient 3.01 Understand Diagnostic and Therapeutic Services

9. Career Responsibilities: Diagnostic and Therapeutic Services Evaluate care • Patient response to treatment and/or procedure • Implementation of the procedure • Function of equipment • Personal performance • Analysis of information gathered • Revision of treatment plan based on information gathered Evaluation is a continual process 3.01 Understand Diagnostic and Therapeutic Services

10. Objective 3.01 Collect Patient Data

11. Essential Question • How is patient data collected and reported? 3.01 Understand Diagnostic and Therapeutic Services

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

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

19. 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

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

21. 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

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

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

24. 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

25. 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

26. 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

27. Collect Patient DataPatient Assessment Using medical instruments

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

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

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

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

32. 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

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

34. Collect Patient DataPatient Assessment Using medical instruments Stethoscope used to listen to internal body sounds 3.01 Understand Diagnostic and Therapeutic Services

35. 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

36. Vital Signs • Provide information about body function • Include: • temperature • pulse • respiration • blood pressure • Changes may be the first sign of disease • Accuracy is imperative! 3.01 Understand Diagnostic and Therapeutic Services

37. Vital SignsTemperature • Measurement of the balance between heat lost and heat produced • Heat lost through: • Perspiration • Respiration • Excretion • Heat produced by: • Metabolism of food • Muscle and gland activity 3.01 Understand Diagnostic and Therapeutic Services

38. Vital SignsTemperature Normal ranges • 97º - 100º F • 36.1º - 37.8º C 3.01 Understand Diagnostic and Therapeutic Services

39. Objective 3.01 Record and ReportPatient Data 3.01 Understand Diagnostic and Therapeutic Services

40. Record Patient Data • Patient data must be recorded accurately. • Document procedures as you do them. • Use the proper format and appropriate forms. • Record results in BLUE or BLACK ink. 3.01 Understand Diagnostic and Therapeutic Services

41. 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

42. Record Patient DataSOAP Notes • Subjective observations: what the patient states (symptoms) • Objective observations: what is seen or measured (signs) • Assessment: normal versus abnormal • Plan: what will be done 3.01 Understand Diagnostic and Therapeutic Services

43. Record Patient Data Subjective observations: what the patient states (symptoms) • “My tooth hurts.” • “My jaw aches.” • “I bit my tongue.” 3.01 Understand Diagnostic and Therapeutic Services

44. Record Patient Data Objective observations: what is seen or measured (signs) temperature color amount or size blood pressure location

45. Record Patient Data • Assessment: normal versus abnormal 3.01 Understand Diagnostic and Therapeutic Services

46. Record Patient Data • Plan: what will be done? 3.01 Understand Diagnostic and Therapeutic Services

47. Record Patient DataSOAP Notes • Subjective observations: what the patient states (symptoms) • Objective observations: what is seen or measured (signs) • Assessment: normal versus abnormal • Plan: what will be done 3.01 Understand Diagnostic and Therapeutic Services

48. Record Patient Data Subjective or objective? 3.01 Understand Diagnostic and Therapeutic Services

49. Record Patient Data Subjective or objective? 3.01 Understand Diagnostic and Therapeutic Services

50. Record Patient Data Subjective or objective? 3.01 Understand Diagnostic and Therapeutic Services