Patient Assessment, ASA classification, documentation Flashcards
What is a class one mallampati score
full visibility of tonsils, uvula, and soft palate
What is a class two mallampati score
hard and soft palate visible, upper portion of tonsils and uvula visible
What is a class three mallampati score
hard and soft palate visible, base of uvula visible
What is a class four mallampati score
only hard palate visible
What is the significance of a mallampati score
the higher the mallampati score, the more difficult it is to intubate the patient.
What is the outline for written documentation
SOAP Subjective (what the patient tells you, CC) Objective (your findings, measurements) Assessment (diagnosis, conclusion) Plan (planned and performed treatment)
What is the outline for Oral communication
SBAR
Situation (what’s going on with the patient)
Background (How did we get to this point)
Assessment (What do you think the issue is)
Recommendation (What do you recommend we do)
Results through relationships, Relationships before tasks
Results through relationships, relationships before tasks
What kinds of things do you look for as a general assessment
countenance (happy or sad)
Distress (pain) of no acute distress (NAD)
Physically healthy or not
What should you remember when doing a general assessment
you need to make judgements, but you should not be judgemental
What is the History of present illness (HPI)
an elaboration on the patient’s chief complaint. relevant symptoms and characteristics of the symptoms
What does PMH stand for
Past medical History
What does PDH stand for
Past dental history