Holistic Care Flashcards
Hollistic Care
Hollistic care includes assessing the patient’s health status with physical
Psychological
Social
Spiritual. Behavioral data
Consider all these
Medical history: collecting the information
- In addition to being useful for diagnosing and treating the patient to self history allows the patient to more participation in the process
- The floor maybe mail to the patients home before the appointment or maybe completed in the office during the visit
- If you are responsible for taking a portion of the medical history conduct the interview in a private area free from outside interference and beyond hearing range of other patient
Collecting the medical information
The interview room should be physically comfortable in conductive to confidential communication
•Do not express surprise or displeasure at any of the patient statement
• Record the information in an organized manner exactly is given by the patient without opinion or interpretation
• include CC, vital signs weight, height, pain scale
The medical history
Consists of: Patients database past medical history (P.M.H) family history (FH) social history (SH) review of systems (ROS)
Understanding and communicating with patients
Positive reactions and interactions with patients are essential for a therapeutic relationship
• interpersonal nature of the patient-medical assistant relationship carries with it a certain amount of responsibility to detach one’s self interest and focus on the needs of patients
Sensitivity to diversity
- EMPATHY is the key to creating therapeutic environment
* Required those interested in healthcare services to examine their own values believes and actions
Therapeutic technique:
active listening
Listening must be an active process and therapeutic relationship
• restatement-paraphrasing patient statements and comments
• reflection-repeating the main idea of convo
• clarification-summarization of senders thoughts and feelings
Therapeutic techniques: non-verbal communication
- approximately 90% of patient interactions occur through nonverbal language.
- successful patient interaction has congruent(equal) verbal and nonverbal messages.
Prepping the appropriate environment
- ensure privacy
- refuse interruptions
- prepare comfortable surroundings
- take judicious notes
Open-ended question
Gives the patient the opportunity to provide additional information
Close-ended question
Ask for specific information that can be answered with only a few words
Interviewing the patient
•Contract between the medical assistant and
• three parts
-initiation or introduction
-The body
-The closingInterview barriers
Providing unwarranted assurance
Giving advice
Using medical terminology
Talking too much
Using defense mechanism
Communication across the lifespan
Be aware how to interact most effectively w young children, adolescents adults and they’re fams
Using a specific approach
Health history of a child
Environment should be safe and attractive
• don’t keep children and their caregivers waiting long
• don’t offer choices unless child can make them
Giving choices of stickers after an injection is appropriate
Child’s examination
- praising the child helps decrease anxiety when possible direct questions to child so he feels part of the process
- let child use equipment
- use imagination for games involved in procedure
- look for anxiety signs like thimb sucking or rocking
- typical defense mechanism seen in children is is regression
Treating tees
- involved in treatment
- Provide opportunities for independence
- privacy is very important
- stress Healthy life habits and decisions
Adult patients
- patient education is extremely important
- use Laylanguage and involve the patient in treatment
- stress related health problems are frequently thing
- emphasize preventive health care measures
Patient body system assessment
Appearance head and neck ears mouth Nose throat respiratory cardiovascular urinary limp glands neurologic endocrine skin Geneitalia (men & women) arms legs and feet
Signs and Symptoms
SIGNS- objective findings
Something that can be measured inspected, pal pared, auscultation, or manipulated
SYMPTOMS-subjective report from patient
- patient complains regarding how she feels
- measure pain on scale
- cardinal symptoms those most helpful in diagnosis
28
Functional
Physical
Documentation
- accurate and complete documentation is a necessary skill
- describe patients CC and signs and symptoms With correct use of medical terminology and appropriate abbreviation
Make legal corrections
Charting methods (POMR) Problem Oriented Medical Record
- database
- problem list
- plan
- progress notes (SOAPE)
SOAPE notes
- Subjective data: CC in patients words
- Objctive data: anything observed or measurable
- Assessment: physician’s tentative diagnosis
- Plan of care: physician documents how health problem will be managed
- Evaluation: assessment of treatment outcome
Other charting methods
SOMR-
Source oriented medical record
organized patient data into specific sections
• should be filed in the first chronological order with the most recent report or progress nite on top
EMR- electronic medical record
Patient education
The perfect time to initiate patient education is during the initial patient interview
