Module 3: Patient Admission Flashcards

1
Q

Patient Assessment, An Essential Skill
(AIDET)

A
  • Acknowledge
  • Introduction
  • Duration
  • Explanation
  • Thanks
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2
Q

Warmly greet the patient by
name

A

Acknowledge

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3
Q

Tell the patient who you are (name,title,length of time in the profession) and what will you be doing for them

A

Introduce

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4
Q

Explain how long the exam will take and frequently update the patient of any delays

A

Duration

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5
Q

Describe the exam the patient will be undergoing, this is the opportunity to collect pertinent history

A

Explanation

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6
Q

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

A

Thanks

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7
Q

Information available regarding a patient’s condition; traditionally comprises date on localization, quality, quantity chronology, setting, aggravating, or alleviating factors, and associated manifestations

A

Clinical history

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8
Q

Questioning techniques ( o, f, s, r, c, s)

A
  • Open-ended questions
  • facilitations
  • silence
  • reflection/reiteration,
  • clarification/ probing
  • summarization
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9
Q

Elements of Clinical History – Sacred 7

A
  1. Localization
  2. Chronology
  3. Quality
  4. Severity
  5. Onset
  6. Aggravating or alleviating factors
  7. Associated manifestations
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10
Q

Defining as exact and precise an area
as possible for the patient’s complaint.

A

Localization

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11
Q

Involves using touch to highlight
or specify instructions or specify
locations

A

TOUCHING FOR EMPHASIS

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12
Q
  • 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.
A

Chronology

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13
Q

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.)

A

Quality

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14
Q

Character of the Symptoms

(C, P, S, T, C)

A
  • 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.)
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15
Q

of a condition describes the
intensity, quantity, or extent of the
problem

A

Severity

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16
Q

——– of pain: How severe is it? Mild,
moderate, or severe? (Some like to use
a pain scale of 0 to 5 or 0 to 10, with 0
being no pain at all and the highest
number representing the worst pain the
patient can imagine.) Does it wake you
up at night?

A

Severity

17
Q

A review of the —- can help to determine
whether predictable events preceded the
recurrence of a symptom

A

onset

18
Q

How did it start? What happened? When
did it first trouble you? Was it sudden or a
complaint that gradually got worse?

A

Onset

19
Q

The circumstances that produce the problem or intensify it including anything that aggravates, alleviates, or otherwise modifies it

A

Aggravating Factors

20
Q

What seems to make it worse? When is it worst? Is it worse after meals? At night? When you walk? What has helped in the past?

A

What aggravates/alleviates

21
Q

any other symptoms that accompanies the chief complain

A

Associated Manifestations

22
Q

any other symptoms that you are experiencing that may be related to your chief complaint?

A

Associated Manifestations

23
Q

Requires that any decision that alters
the radiation exposure situation should
do more good than harm;

A

Principle of Justification

24
Q

A contract wherein the patient voluntarily gives permission for someone to perform a procedure or service

A

Consent

25
Q

A Consent should be:
FRIES

A

F – Freely given
R – Reversible
I – Informed
E – Enthusiastic
S – Specific

26
Q

The process by which the health care
provider discloses appropriate
information so that the patient may
make a voluntary choice to accept or
refuse treatment.

A

Informed Consent

27
Q

Informed Consent is required in

A

Invasive procedures
Procedures requiring sedation
Procedures that may carry risk
Procedures that involve radiation

28
Q

Informed Consent should include the following

A
  • The nature of the decision/procedure
  • Reasonable alternatives to the proposed intervention
  • The relevant risks, benefits, and uncertainties related to each alternative
  • Assessment of patient understanding
  • The acceptance of the intervention by the patient
29
Q
  • A clear and direct statement of agreement
  • Communicated either verbally or in written form
A

Expressed Consent

30
Q
  • The patient’s actions imply consent without a verbal or written expression of consent
  • May be necessary in emergency procedures such as CPR to save person’s life
A

Implied Consent