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
——– 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?
Severity
A review of the —- can help to determine
whether predictable events preceded the
recurrence of a symptom
onset
How did it start? What happened? When
did it first trouble you? Was it sudden or a
complaint that gradually got worse?
Onset
The circumstances that produce the problem or intensify it including anything that aggravates, alleviates, or otherwise modifies it
Aggravating Factors
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?
What aggravates/alleviates
any other symptoms that accompanies the chief complain
Associated Manifestations
any other symptoms that you are experiencing that may be related to your chief complaint?
Associated Manifestations
Requires that any decision that alters
the radiation exposure situation should
do more good than harm;
Principle of Justification
A contract wherein the patient voluntarily gives permission for someone to perform a procedure or service
Consent
A Consent should be:
FRIES
F – Freely given
R – Reversible
I – Informed
E – Enthusiastic
S – Specific
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.
Informed Consent
Informed Consent is required in
Invasive procedures
Procedures requiring sedation
Procedures that may carry risk
Procedures that involve radiation
Informed Consent should include the following
- 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
- A clear and direct statement of agreement
- Communicated either verbally or in written form
Expressed Consent
- 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
Implied Consent
