Documentation, ROS, and Skills Flashcards
Clinician must possess
- strong assessment skills
- eagerness to learn
- desire to give high quality care
- patience
- passion to help others
- ability to leave prejudice at the door
Subjective v. Objective
- Subjective - Based on or influenced by personal feelings or emotions
- Objective - Not influenced by personal feelings or opinions in considering a representing facts
Physical examination
an evaluation of the body and its functions
PE Techniques
- Observation
- Palpation
- Percussion
- Auscultation
Look, Listen, Touch, smell
Why Critical observation is important?
Observe, carefully and thoughtfully. The PE is an important component of clinical diagnosis.
Clinicians need to use an unbiased visual observation and inspection.
This interested observation, canprovide critical accurate information to the diagnostic exam.
Palpation
Examination by:
Pressing on the surface of the body to feel the organs or tissues underneath
Percussion
A method of tapping body parts with fingers, hands, or small instruments as part of a physical examination.
Auscultation
Listening to sounds of the body during a physical exam.
PE process
- The process of
evaluating objective anatomic findings through the use of:
Observation, Palpation, Percussion, and Auscultation. - The information obtained must be thoughtfully integrated with the patient’s history and pathophysiology.
- A thorough Physical Exam covers head to toe.
It measures important vital signs
Temperature
Blood pressure
Heart rate
Respiratory Rate
Initial part of physical exam
- Speech and appearance of Pt.
Vital Signs
Useful in detecting or monitoring medical problems.
Vital signs can be measured in a medical setting, at home, at the site of a medical emergency, or elsewhere.
Four main vital signs
- HR
- BP
- Respiratory Rate
- Body Temp
What is considered an objective Fever?
at or greater than 100.4 f
Pulse taking locations
- Radial
- Carotid
- Femoral
Lower extremity -
1. Posterior tibial
2. Popliteal
3. Dorsalis pedis
Reference systolic pressures without reading
- Carotid - >80
- Femoral - >70
- Radial - > 60
5 Main blood Pressure ranges
by the JNC
- Normal <120/ <80
- Elevated - 120-129/ <80
- Stage 1 Hypertension -
130-139 / 80-89 - Stage 2 Hypertension -
140-149 / 90-99 - 150+ / 100+
How to measure respiratory rate
count the number of breaths for an entire minute or count for 30 seconds and multiply that number by two
What should you do prior to performing a physical examination on your patient?
1) Review the chart/including vs
2)Appear presentable
3) Create patient privacy
Entering a patient room…
Knock on the door/wall
Introduce yourself
Verify pt’s name
Check ID bracelet
Make eye contact
Try to be at the pt’s physical level
Take notes
Repeat the plan back to the pt
Pt. Interview techniques
- Carefully attending to what the pt is endorsing
- Connect to the pts emotional state
- Use verbal and nonverbal skills to encourage the pt to expand on his or her feelings or concerns
- Ask one question at a time
- Clarify what the pt means
When to use closed ended questions?
Use close-ended questions when you need a specific piece of information.
Does this hurt when you stretch?
The pain started today, right?
Are you feeling better today?
Do you have covid sxs?
Interview approach overview
Start with Open-ended questions to hear “the story of the sxs”on the pts own words
Ask specific questions to elicit every symptom
End with closed-ended questions for the yes or no answers for “pertinent positives/negatives” for your ROS
Non verbal communication
- Consciously and unconsciously, you send messages through words and body-language
- Posture, gestures, eye-contact with certain tone of voice can let the pt know if you are interested, attentive, or understand their concern.
- Eye contact
Posture
Use of touch
Staying silent
Head nodding
Facial animation
Some forms of non-verbal communication are culturally bound
What should you never assume in patient care?
- Pt understands completely
- Have the patient reiterate your plan
Patient concerns to be mindful of.
Earnings
Education status
Inequalities of health care access
Language Proficiency
Pt care decision
Implicit Bias
A set of unconscious philosophy or associations that lead to a negative evaluation of a person based on their perceived group identity
This can negatively affect the patient encounter and contribute to disparities among various demographic groups
Explicit Bias
The conscious and intentional decisions or preference is founded on beliefs of stereotypes or association based on a perceived group identity.
Patient characteristics such as race, gender, sexual orientation, or age can influence aspects of the patient encounter.
Medical ethics
Beneficence (doing good)
Non-maleficence (do no harm)
Autonomy (giving the patient the freedom to choose freely, where they are able)
Justice (ensuring fairness)
Informed Consent
Communication process in which a clinicals educates the patient about the risk/benefits/alternatives of a given procedure or intervention
Be sure your patient has decision capacity, if not, please use a health care proxy
Use an interpreter if needed
Document
Nature of the procedure and tx
Risks
Benefits
Cinical encounter documentation
Goal: document in the pts health record to provide clear, concise, and detailed report that documents key findings and communicates your assessment in a brief format
Must have order and clarity
Almost all clinical information is subject to error as pts forget to mention certain sxs, fail to recount events of their illness, slant their stories.
Clinicians can misinterpret pt. statements. Overlook info. Failed to inquire the one key question. React prematurely to dx and forget about the important part of the examination
Keys for objectivity
Effective listening and feedback
Patient expectations of clinicians
Empathy, Care, Compassion
Ability of Clinician to listen and explain
Knowledge/Skill
Professionalism
Show cultural competency/humility
4 main areas of PE
1) Health/Medical History
2) Physical Examination
3) Clinical Reasoning and
Assessment
4) Treatment Plan
H&P categories
CC(Chief Complaint)
HPI(History of Present Illness)
Pmhx (Past Medical History)
Pshx (Past Surgical History)
Meds (Medications)
Allergies
PFHX (past Family history)
Social Hx
ROS (Review of Systems)
Exam
Labs
Images/Other studies
A&P (Assessment & Plan)
CN VII/Facial nerve check
smile / frown
