Module 3: Patient Admission Flashcards
Patient Assessment, An Essential Skill
(AIDET)
- Acknowledge
- Introduction
- Duration
- Explanation
- Thanks
Warmly greet the patient by
name
Acknowledge
Tell the patient who you are (name,title,length of time in the profession) and what will you be doing for them
Introduce
Explain how long the exam will take and frequently update the patient of any delays
Duration
Describe the exam the patient will be undergoing, this is the opportunity to collect pertinent history
Explanation
Express gratitude to the patient for choosing your facility for his/her care, for exhibiting patience, for being positive throughout the exam, and so forth
Thanks
Information available regarding a patient’s condition; traditionally comprises date on localization, quality, quantity chronology, setting, aggravating, or alleviating factors, and associated manifestations
Clinical history
Questioning techniques ( o, f, s, r, c, s)
- Open-ended questions
- facilitations
- silence
- reflection/reiteration,
- clarification/ probing
- summarization
Elements of Clinical History – Sacred 7
- Localization
- Chronology
- Quality
- Severity
- Onset
- Aggravating or alleviating factors
- Associated manifestations
Defining as exact and precise an area
as possible for the patient’s complaint.
Localization
Involves using touch to highlight
or specify instructions or specify
locations
TOUCHING FOR EMPHASIS
- The time element of the history.
- This refers to the duration since onset,
frequency, and course of the symptoms. - Described in seconds, minutes, hours, days, weeks, or months.
Chronology
Describes the character of the symptoms:
* Color and consistency of fluids
* Presence of clots or sores
* Size of the lumps or lesions
* Type of cough
* Character of pain (acute or chronic,
burning, throbbing, dull, sharp,
cutting, aching, prickling, radiating,
pressure, and crushing.)
Quality
Character of the Symptoms
(C, P, S, T, C)
- Color and consistency of fluids
- Presence of clots or sores
- Size of the lumps or lesions
- Type of cough
- Character of pain (acute or chronic,
burning, throbbing, dull, sharp,
cutting, aching, prickling, radiating,
pressure, and crushing.)
of a condition describes the
intensity, quantity, or extent of the
problem
Severity