HISTORY TAKING Flashcards
What are the ROLES OF A RADIOGRAPHER?
- The radiographer obtains a clinical history of the patient to assist the radiologist in diagnosing.
- The radiographer is responsible for recording information on the requisition.
- The radiographer must check all information included on the x-ray requisition for accuracy.
It is the radiographer’s responsibility to?
clarify any questionable information on the requisition.
Examples:
* Wrong part, side, exam
* Wrong patient, sex, DOB
* Questionable Hx or Dx
* Contraindications
What is an X -RAY REQUISITION?
The x-ray requisition is the formal order for a diagnostic procedure and is a medical legal document.
What Information do you find on an x-ray requisition?
-Patient Name
-Sex of patient
-Diagnosis (Dx) and pertinent clinical history (Hx)
-Date of exam and date when arrived
-Date of Birth (DOB)
-Signature of the requesting physician
-Pregnancy status and LMP (last menstrual period)
-Medical record number and insurance information
How do you greet a PATIENT AS A RADIOGRAPHER?
- First introduce yourself and explain you’re the radiographer
- Ask the patient their name and check wristband for inpatient
- Always address patient by their last name, Mr or Mrs
hOW DO YOU INTERVIEW A PATIENT?
The radiographer should:
-Speak slowly and clearly
-Listen to the patient
-Maintain eye contact with the patient
-Use language that the patient can understand
-Ask only one question at a time
What are some Interviewing a Patient – Do’s ?
-Ask open-ended non-leading questions
-Facilitation
-Silence
-Probing questions
-Repetition
-Summarization
Explanation of each
Ask open-ended, non-leading questions - to let the patient tell their story
Facilitation (nodding, saying yes or no) - to encourage elaboration
Silence (giving patient time to remember) - facilitates accuracy and elaboration
Probing questions (to focus the interview)
Repetition (rewording) clarifies information
Summarization (condensing) verifies accuracy
What are some Interviewing a Patient – Don’ts?
(-Do Not Ask Patients Personal Questions )
-Instead ask questions relevant to the study that will aid in Diagnosis.
-Communication is key
Do Not Ask Patients Personal Questions When Interviewing a Patient
Patients may not want to talk about their illness or injury – the radiographer should respect that.
Ask questions that will help the radiologist with the Dx.
Positive Patient/Radiographer Interactions
Most important – talk/communicate with your patient.
Ensure That the Best Radiographers Cane Be Taken
This will lead to correct technique, positioning and an optimal study.
Data Collection Process
Most patients understand the importance of a history and will provide information as requested.
Remember, the information needed by the radiologist is specific to the patient’s reason for the examination.
Never disregard anything the patient says, especially if it does not fit with the opinion you are forming about the patient’s symptoms
WHAT IS OBJECTIVE DATA?
data that is observed and collected during the physical exam and are detectable to the observer.
Signs that can be seen, felt or heard i.e. lab tests, discolored skin or swelling of soft tissues, elevated Blood Pressure (BP) reading.
What are features of Objective Data?
-Perceptible to the senses
-Signs that can be seen, heard, felt
Able to be measured
-Often physiologic
WHAT IS SUBJECTIVE DATA?
data that can be perceived only by the affected individual (the patient).
Subjective data is what the patients feels, their sensations, values, beliefs, attitudes, and their perception pf their health status, i.e. pain, intensity of pain, itching, feelings of worry.
What are features of subjective data
-Patient feeling
-Pain level
-Attitude
-Opinion of the observer
-Subject to interpretation
What are elements of a clinical history HX?
Chief complaint
MDs tend to focus on this.
Permit the patient to add more than a single complaint when it appears multiple complaints are valid.
Ignoring all symptoms except the most predominant can cause you to miss other important clinical information
What is Chief Compliant?
the medical condition for which the patient is seeking treatment. I.e. Pain, Dizziness, Vomiting, Fainting, Cough, Headache, Numbness, and Burning.
What are the SACRED 7?
- Localization
- Chronology
- Quality
- Severity
- Onset
- Aggravating or alleviating factors
- Associated manifestations
What is Localization?
Localization - the exact area the complaint. (i.e. posterior surface of the left knee)
What is Chronology?
Chronology – the time element in history. (i.e. shortness of breath while exercising)
What is QUALITY?
Quality – describes the character of the symptoms. (i.e. dark urine, size of a lump, type of cough)
What is SEVERITY?
Severity – the intensity and quantity of the symptom.(i.e. severe and sharp headache or dull ache)
What is ONSET?
Onset – when the symptom began. (i.e. after falling down a day earlier)
What are Aggravating or alleviating factors?
Aggravating or alleviating factors – what makes the symptom worse or better.(bed rest relieves the pain)
What are Associated manifestations?
Associated manifestations – any other symptoms that accompany the chief complaint.(gastric pain and headaches
What is INFORMED CONSENT?
Conditions for Valid Consent usually for invasive procedures such as special procedures and IV contrast injection procedures and the instillation of a contrast agent other than orally or rectally.
Can be written or oral or implied.
(full explanation of the procedure including risks and benefits)
What is a CONSENT FORM?
Note:- The consent form is a separate form from the general admissions forms signed by the patient. A full explanation of procedure including risks and benefits.
INFORMED CONSENT
- Informed Consent is based on full disclosure of the facts allowing the patient to make a decision.
What is INFORMED CONSENT ALSO CALLED?
VALID CONSENT
When is an Informed Consent used?
Patient must be mentally competent and of legal age to make an informed consent. (OF SOUND MIND AND LEGAL AGE)
Consent must be voluntary. (FREELY)
Consent must be signed by the parent or legal guardian for minors AND MENTALLY ILL IDIVIDUALS
Adult patient may have a legal
guardian also.
The patient must be adequately informed about the procedure about to take place.
Explanation of procedure must be in terms that the patient understands.
What is IMPLIED CONSENT?
Provides care when the patient is unconscious and is based on the assumption that the patient would approve if conscious.
provides care when the patient is unconscious or injured in a way that they are unable to give consent. Treatment is based on the assumption that the patient would approve if able or conscious.
I.e. During an emergency when the patient is unconscious and not able to communicate, treatment could be provided without a signed consent because “implied consent” would apply.
What is SIMPLE CONSENT?
Patient agrees with no explanation
What is Confidentiality?
to hold in strict confidence any information learned about a patient in the course of medical treatment. (i.e. patient records, results
What is HIPAA?
The federal health insurance portability and accountability act of 1996
Now let’s talk about PATIENT RIGHTS,
WHAT IS PATIENTS BILL OF RIGHTS?
Informs patients about their rights.
What is privacy?
The right to be left alone, the right of a person to be free of unwanted publicity
What is Advanced Directives?
Pt’s make their rights legally known before they become incapacitated. (DNR)
What is Access to Information?
a patient has to right to access their medical reports/information.
What is a living will?
A document that allows the patient to state their wishes for end-of-life care,
it has no power after death
What is Health Care Proxy?
Patient names a person to be their spokesperson if they become incapacitated.
What is Research participation ?
A patient has the right to decide whether or not they want to participate in research.
What are some LEGAL ISSUES?
-BATTERY
-DUTY
-BREACH
-TORT:
-NEGLIGENCE
-UNINTENTIONAL NEGLIGENCE
-INVASION OF PRIVACY
-ASSUALT
-VIOLATION OF PROFESSIONAL CONDUCT
-MALPRACTICE
-FALSE IMPRISONMENT
-DEFAMATION OF CHARACTER
What is BATTERY?
unlawful touching of another person that is without justification or cause.
· Touching without consent or explanation.
· Performing a study against a patients will.
· Physical harm as the result of an exam.
· May include x-raying the wrong patient, part.
What is DUTY?
what should have been done.
What is a BREACH?
deviation from duty.
What is a TORT?
tort is a violation of civil law (personal injury law): it may be intentional or negligent.
Some terms associated with tort law are:
-NEGLIGENCE
-UNINTENTIONAL NEGLIGENCE
-INVASION OF PRIVACY
-ASSUALT
-VIOLATION OF PROFESSIONAL CONDUCT
-MALPRACTICE
What is NEGLIGENCE?
unintentional misconduct. Neglect of reasonable care.
What is UNINTENTIONAL NEGLIGENCE?
(i.e. failure to provide gonadal shielding)
What is INVASION OF PRIVACY?
examples:
· Violation of confidentiality.
· Improperly touching a patient.
· Taking radiographs without the patient’s permission
What is an ASSAULT?
any willful attempt or threat to inflict injury.
What is Violation of Professional Conduct?
- Violation of Professional Conduct of the radiographer that causes the patient to fear. (i.e. verbally threatening more films, longer exams etc.)
What is MALPRACTICE?
professional negligence that causes injury or harm to the patient.
WHAT ARE 2 TYPES OF MALPRACTICE?
-FALSE IMPRISONMENT
-DEFAMATION OF CHARACTER
WHAT IS FALSE IMPRISONMENT?
unjustified restraint or restraining a patient against their will.
WHAT IS DEFAMATION OF CHARACTER?
Any intentional false communication, written or spoken, that harms a person’s reputation; decreases the respect, regard, or confidence in which a person is held.
WHAT ARE THE 2 TYPES OF DEFAMATION?
-SLANDER
-LIBEL
WHAT IS SLANDER?
verbally spreading false information.
WHAT IS LIBEL?
written information that result in defamation of character or loss of reputation.
What are the LEGAL DOCTRINES ?
· Res ipsa loquitur-“ the thing speaks for itself”. This means that the negligence is obvious. (i.e. x-raying the wrong side)
Respondeat superior- “The master speaks for the servant”.
Employer will be held responsible for the employee’s actions. But not in the case of negligence.
Rule of Personal Responsibility -
Individuals are responsible for their own actions
Identifying Your Patient
- First introduce yourself and explain what you will do.
- Ask the patient his/her name and always check the wristband of inpatients
- Do not call the patients name in a crowded waiting room and assume that the patient answered correctly.
- Double check by asking the patient their name once you are in the radiographic room with some other relevant information such as their DOB.
- Always address patients by Mr., Mrs., etc., and their last name.
- Only address a patient by their first name if they tell you it is OK to do so.
- Double check the identity of the patient – first when calling the patient and then again when you are interviewing them in the x-ray room immediately prior to the procedure.
- If you do not speak the same language as the patient, use an interpreter. The interpreter may be a family member or coworker that can communicate with the patient.
ASSESSMENT OF THE RADIOLOGY PATIENT
The radiographer needs to assess the patient before, during and after the x-ray procedure.
BEFORE
- Identify the patient.
- Confirm age and DOB
- Confirm that the correct exam has been ordered.
- Record a brief Clinical Hx on the requisition.
- Assess the patient’s general condition and ability to cooperate during the exam.
- Check Pregnancy status by verifying LMP.
- Check for the allergies if applicable.
- Check for metal artifacts if applicable i.e. MRI
DURING
Continuously monitor the patients’ health and vital signs throughout the procedure based on the patient’s condition.
Reassure the patient throughout the procedure.
AFTER
Record any problems or concerns on the requisition or patient’s chart.
Example:
* Patient unable to hold still due to Parkinson’s disease.
* Patient unable to rotate wrist completely due to pain and swelling.
* Patient complains of lower, right-sided abdominal pain.
Discuss with the patient what will happen after the exam.
Depending on the clinical Hx and/or the limitations of the patient the radiographic procedure may be modified.
Such as:-
* Change in radiographic technical factors.
* Change in position/projection
All changes and the reason for the change should be notes on the requisition and /or chart.
REFUSAL OF X RAY EXAM
It is the patient’s right to refuse medical treatment including radiographic procedures.
The radiographer should try and explain why the doctor order the exam.
Explain the procedure to the patient and how it will benefit the patient by helping the doctor to make a diagnosis.
GIVING RESULTS TO THE PATIENT
Simple it is NEVER done by the Radiographer
A radiographer should never diagnose, interpret radiographs or give results of an x-ray exam to a patient.
It is not in the ARRT Scope of Practice to diagnose radiographs or give results to the patient or family members
When asked what the results of the exam are, the patient should politely be instructed to ask his referring doctor .
It is Ok to tell the patient that you are not permitted to interpret the x-rays.
However remember that patients are often anxious about the results.
Explain the procedure they should follow for obtaining the results for their x-ray exam.
What is VALIDATING DATA?
The radiographer should initial or signs any information that they add to the x-ray request or patient record.
The radiographer will also mark the films with lead markers that will identify who took the radiographs.
CONCLUSION
Consider the patient history as an interview with the patient.
Demonstrate respect, compassion, and empathy for the patient’s condition.
Clearly identify the patient’s chief complaint.
Gather all pertinent information relative to the procedure.
What is a CLINCAL HISTORY?
Information available regarding a patient’s condition
What is a clinical history comprised of?
Localization, Quality, Quantity, Chronology, Setting, Aggravating or Alleviating factors, and associated manifestations
What are LEADING QUESTIONS?
Undesirable method of questioning; provides information that may direct answers toward a suggested symptom
WHAT ARE CONTRAINDICATIONS?
A contraindication is a situation where a patient should not receive a treatment or procedure because it may be harmful. Contraindications can be related to a patient’s medical condition, symptoms, or other factors. They can also be related to the combination of a patient’s medications or food with a treatmenT
MEDICAL ABBREVIATIONS
AP - Anteroposterior
PA – Posteroanterior
LAT – Lateral
OBL - Oblique
CXR – Chest x-ray
BP – Blood Pressure
Abd - Abdomen
ABX – Abdominal x-ray
KUB – Kidneys, Ureters and Bladder
Hx or HX - History
Fx or FX - Fracture
MVA – Motor Vehicle Accident
GSW – Gun Shot Wound
DOB – Date of Birth
R or Rt or RT – Right
L or Lt or LT – Left
c/o – complains of
LMP – Last Menstrual Period
PE – Physical Exam
Pre op – before surgery
Post op – after surgery
pt or Pt or PT - patient
stat or STAT - Immediately
ARDS – Acute respiratory Distress Syndrome
CA - Cancer
R/O – Rule out
