Assisting the Physician Flashcards
A complete patient examination consists of 3 parts:
Health History
Physical examination of each body system
Laboratory & diagnostic tests
Guidelines for patient exam/charting
SOAP (whether sore throat or CPX)
SOAP
S Subjective: What the patient feels. Perceived/felt only by the patient. i.e.: pain, aches, dizziness.
O Objective: What a physician detects when examining a patient.
A Assessment: Conclusion of above findings.
P Plan: Plan for treatment or diagnostics.
Complete Physical Examination, Responsibilities of the MOA
Clinical responsibilities vary widely.
a. Communicate with the patient & physician easily & effectively.
b. Evaluate the patient’s needs and respond to these.
c. Follow the physician’s instruction quickly, accurately & confidentially.
Purpose of the CPX (complete physical examination)
To determine the overall state and well-being of the patient.
The physician forms an initial diagnosis regarding the patient’s condition.
Lab and diagnostic tests may be ordered; these can be used to help the doctor in planning treatment, maintaining drug therapy, or in evaluating the patient’s progress.
Due to the focus on health care & wellness, the patient is becoming more aware of the need for yearly check-ups to detect early signs of illness and to prevent serious health problems. A physical examination may be a prerequisite for employment, participation in sports, admission to school, driver’s licenses, etc.
Preparation of the examining room
Proper preparation of the examination room provides a comfortable health environment for the patient and facilitates the physical examination.
Guidelines that should be followed in preparing the exam room.
Check for ample supplies. Restock supplies that are getting low or outdated.
Replace sharps containers as necessary.
Maintain room temp that are comfortable for pt’s as and when they disrobe.
Clean and disinfect examining tables, countertops, faucets and door knobs daily. Remove dust and dirt from under the beds and towel dispensers.
Change the examining table paper after each pt by unrolling a fresh length. Check to make sure there is an ample supply of gowns and drapes ready for use.
Patient’s privacy should be ensured. The MOA is responsible for making sure that the door is closed/and or curtain is pulled during the exam.
Properly clean and prepare equip., instruments and supplies that will be used for pt exams so that they are ready for use by the physician.
Check equip. and instruments regularly to verify that they are in proper working condition.
Have the equip. and supplies ready for the exam. They should be arranged for easy access by the physician. The equip. and supplies needed for the physical exam vary according to the type of exam and the physician’s preference.
