Patient Care Flashcards
1
Q
Preparing for patient visit
A
- ensure room is clean and proper instruments needed for next appointment are on tray
- get clipboard
- begin ema note: document main complaint and pull over most important impressions from previous visits, start up the ROS and exam details, etc.
- if pt is new, document medical history, medications, allergies, pharmacy, and ROS from PHREESIA
2
Q
Rooming the patient
A
- greet pt, call their FIRST name
- confirm pt DOB
- introduce yourself, state who pt will be seeing
- collect HPI and ROS
- provide pt with gown/sheet
3
Q
Collecting HPI
A
- review pt’s medications, allergies, and pharmacy. if any changes, document them. Mark as reviewed.
- for skin check: ask if any spots of concern and document in HPI block
- follow up on conditions discussed at last visit and ask about condition and concerns
- for follow up: ask how condition is doing and if they are following treatment regimen. document in HPI block
- check if pt is overdue for skin check and talk to provider about if you should offer one
4
Q
Collecting ROS
A
- Skin checks / follow ups: ask if rash and changing mole. document. hit reviewed button
- melanoma checks: give pt handout sheet in room. document. hit mark all reviewed. save
- new patients: mark all reviewed, fill in based on phreesia attachment