Unit 6 Lesson 5: Fact or Opinion Flashcards
data
data—bits of information, especially facts and statistics, collected to analyze and assist in making decisions.
How many types of data are in the healthcare industry
There are two different types of data we will be working with in healthcare.
What is subjective data
Subjective data is information communicated to the healthcare professional by the patient and cannot be measured.
What does subjective data include
This includes patient reports of symptoms and events, and this data is not always reliable.
What is an example of subjective data
For instance, a patient may tell you that they feel like they have a fever, yet when you measure their temperature, it is normal. It doesn’t mean that the patient is lying (though that is possible), but it includes the patient’s viewpoint which is not strictly factual.
What is objective data
Objective data, on the other hand, is information that you gather through your five senses or through laboratory or diagnostic tests.
What kind of objective data might you discover during a physical examination
When you perform a physical examination, you will discover objective data, possibly including skin color, swelling, an unusual breathing sound, a lump under the skin, and many other facts.
During a physical exam, you will often be collecting data on the patient’s vital signs what are vital signs
ital signs—measurements of the body’s basic functions including temperature, pulse and respiratory rates, and blood pressure.
Objective data can include
x-rays, blood test results, and any other diagnostic tests in addition to what you can see, smell, feel, and hear.
To collect objective data, you will need to develop your skills of
observation—the act of carefully noticing and perceiving in order to collect information
Visual observation
Visually observe anything you can about the patient, including body language and visual assessment of the body.
What to do when recording data
When you record data in the EMR, you will need to differentiate between subjective and objective data, making sure to note what information was told to you by patients vs. what you have observed with your senses and equipment. In EMRs, there will be different places and formats required for particular information
One very important principle in oral reports is that you normally report events in
chronological order
What happens when healthcare communication is unsuccessful, such as in cases of patient mistrust in the healthcare system, missed opportunities for patient education, and patients who don’t follow through on instructions for home care?
In fact, a recent study showed miscommunications were to blame for over 1,700 deaths in the United States over a five-year period. If a patient concern is not followed up on, a life-threatening condition can be missed. If the healthcare team does not communicate with each other, costly—in terms of money, lives, and suffering—errors can happen.
