Week 3 Flashcards
When taking a patient history, it is important to:
- remain very impersonal and show little emotion or empathy toward the patient.
- consistently call the patient by his or her first name to establish instant credibility.
- maintain a polite and professional demeanor when gathering information.
- consistently call the patient by his or her first name to establish instant credibility and maintain a polite and professional demeanor when gathering information
maintain a polite and professional demeanor when gathering information.
In preparing to radiograph a patient who has come to the medical imaging department with a complaint of abdominal pain, you begin to question the patient as part of the history. A good initial question to ask the patient would be:
“Did you have any problem with parking here at the hospital?”
“Can you tell me about the nature of your pain?”
“Your request states that you have stomach pain, is that correct?”
“Have you seen your doctor about the pain?”
“Can you tell me about the nature of your pain?”
As a patient begins to explain his reasons for coming to the clinic for a radiographic examination, he begins to use medical terms to describe his conditions. His information appears to be accurate medically and helps clarify his symptoms. To deal with this patient, you should:
politely listen, record his comments, and repeat his statements to clarify.
ask him if he is a doctor and tell the radiologist.
determine if he knows what he is talking about by quizzing him on basic anatomy.
disregard his information and record your impressions of his symptoms.
politely listen, record his comments, and repeat his statements to clarify.
In determining a patient’s description of his or her pain, a good question to ask would be:
“How would you describe the pain?”
“When did the pain first happen?”
“If the pain comes and goes, how often does it occur, and what is the time span between occurrences?”
All of these
All of these
When taking a patient history, a competent medical imaging professional:
relates his or her personal experiences to the patient’s, when taking a history.
uses “pet names” such as “dear,” “cutie,” and “honey” to encourage the patient to provide more intimate information about his or her condition.
relies exclusively on objective patient data so as not to bias the patient history.
does none of these things.
does none of these things
On a patient’s examination requisition for a KUB, you notice that the history recorded by the emergency department staff states “R/O appendicitis.” In an effort to gain more precise information about the patient’s condition, questions to ask that would be important to this examination (KUB) would be:
- “How would you describe the pain?”
- “Have you had previous appendix surgery?”
- “Do you know if the emergency department called in a sonographer?”
- “Can you touch the area that specifically hurts?”
- “Are you sure it’s not your kidneys?”
- “Does the pain appear to be in your appendix?”
1 and 4 only
The purpose of a patient transfer is to:
make arrangements for the patient to be moved to another nursing unit.
safely move a patient from one area to another.
provide for the patient’s hospital bill to be deducted from his or her banking institution.
make delivery arrangements for the patient’s personal belongings.
safely move a patient from one area to another.
When moving a patient from a cart to the radiographic table, it would be appropriate to:
ask the patient how much he or she can help with the transfer.
permit the patient to sit up so you can determine their degree of alertness.
allow the patient to safely help with the transfer as much as he or she is able.
ask the patient how much he or she can help with the transfer and allow the patient to safely help with the transfer as much as he or she is able.
ask the patient how much he or she can help with the transfer and allow the patient to safely help with the transfer as much as he or she is able.
When transferring a patient from a wheelchair to a radiographic table,
position the wheelchair at a 90-degree angle to the table.
allow the patient to help with the transfer if it is safe based upon their capabilities.
do not let the patient do any weight-bearing movements.
break the transfer into a series of simultaneous movements and commands
allow the patient to help with the transfer if it is safe based upon their capabilities.
You have received a patient from the nursing floor who needs to be transferred by way of a hydraulic lift. The patient arrives at the medical imaging department on a cart without a transfer sling. To proceed with a safe lift, you should:
set up the patient in a transfer sling and start the lift.
roll the patient over onto a transfer sling.
improvise using a sheet as a transfer sling.
call the nursing floor and return the patient to be placed on a sling.
call the nursing floor and return the patient to be placed on a sling.
For efficient and safe patient transfers and handling, the imaging professional should:
use mobility muscles for posture.
use red postural muscles for support.
narrow the stance and close your fists for extra strength.
keep the knees straight and taut and lift from the shoulders
use red postural muscles for support.
Patient immobilization is a critical part of achieving optimum image quality. Even the smallest, undetectable involuntary motion can degrade the final image. Effective methods to reduce the amount of patient motion include:
giving clear, concise instructions to the patient before the exposure.
assessing the amount of patient cooperation you can expect and making adjustments in immobilization.
explaining how important it is to hold still during the exposure so that a good image can be obtained.
All of these
All of these
Establishing a rapport with a patient contributes greatly to a successful immobilization exercise. To establish patient rapport, the imaging professional should:
explain to the patient how important it is hold still and that you will use restraints to ensure this as part of the exam.
pull out all your immobilization tools in front of the patient to show you know what you are doing.
gently tell the patient what you need to accomplish and how you would like to move forward with the examination.
ask for two or three other technologists to come into the room as you begin the positioning.
gently tell the patient what you need to accomplish and how you would like to move forward with the examination.
A patient arrives at the medical imaging department for a facial bones series after being hit in the head by a softball. The patient comes to you with a cervical collar, but it is apparent that the collar may not be needed because the patient is turning his head to converse with you as the examination starts. A professional imaging technologist would:
remove the cervical collar because it appears to be unnecessary.
complete the facial bone images with the collar in place using the positioning flexibility of your equipment.
call the emergency department nurse and ask her to remove the cervical collar.
immobilize the patient’s head and then remove the cervical collar so it’s not in the image.
complete the facial bone images with the collar in place using the positioning flexibility of your equipment.
Effective techniques to use when radiographing children include:
showing the child a candy treat they will receive if they cooperate.
communicating with the parents exclusively and letting them work with their child.
getting down to eye level with the child and establishing rapport.
asking a uniformed security officer to be in the room during the exam
getting down to eye level with the child and establishing rapport.
The ideal patient immobilization device would be:
robotic and intuitive.
elaborate in design and disposable.
outlined in radiopaque material to show its presence on the image.
radiolucent, durable, and easy to use for the radiographer.
radiolucent, durable, and easy to use for the radiographer.
All of the following would be characteristics of a patient health record except it:
is a single record on a single patient only.
may be maintained in paper or electronic media (or both).
is required for hospitals and emergency department visits only.
promotes communication among providers and continuity of care.
is required for hospitals and emergency department visits only.
A typical health information management department:
charges patients and doctors for its services and is a major revenue center for a hospital.
is responsible for the maintenance, retrieval, and storage of health information.
is considered an essential department and staffed by physicians only.
provides health records to physicians only.
charges patients and doctors for its services and is a major revenue center for a hospital.
The shift to a prospective payment system (PPS) and diagnostic related groups (DRGs) has made the health information process of _____ critically important to the complete and timely reimbursement of medical costs provided by the government (Medicare/Medicaid) and third-party payers.
digitization
archiving
transcription
coding
coding
To maximize the full reimbursement for a diagnostic study performed in medical imaging,
the correct DRG must be attached to inpatient studies performed.
any changes to radiology’s examinations must be communicated with the hospital chargemaster so that the correct CPT-4 code is assigned.
the correct CPT code must be assigned using the ICD-10-CM nomenclature.
All of these are correct
All of these are correct
Patient health records are considered
legal documents
Mammography Quality Standards Act
a patient can request her images be sent to another mammography service
HIPAA and regulations
enacted in 1996, was established to ensure the healthcare industry is focused on the need to protect health information from inappropriate access or use.
also supports the need for timely access to health information while remaining private.
There are eight parts: See page 352 for the full list.
Health information confidentiality and your responsibility
You may not access any records including your own without proper procedure.
If a correction is needed in a patient chart:
use the word ERROR
Imaging quality assurance programs: What items are to be considered?
Efficacy
Appropriateness
Availability
Timeliness
Effectiveness
Continuity
Safety
Efficiency
Respect and caring
An effective hospital quality improvement program includes:
operations and effectiveness of staff.
Quality assurance programs:
seeks improvement of dept.
ICD-10-cm codes for radiology using CPT codes range from
70010-79999
Know what is needed to receive full reimbursement for a diagnostic study
The correct CPT code using the ICD-10-CM nomenclature.
any changes to radiology’s examinations must be communicated with the hospital chargemaster so that the correct CPT-4 code is assigned.
the correct DRG must be attached to inpatient studies performed.
If it is not documented:
it was not done!
DRGs vs APCs
DRG - diagnosis-related group - categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay.
APC - Ambulatory Payment Classification - based on ICD-10-CM codes for diagnosis and CPT codes used for reimbursement to health care in an
outpatient setting
Entering information into the patient record must be done in legible ink when it’s written
(comment)
(comment)
The key function performed by the patient’s health information record is
Communication
Information included in health records
Patient ID and demographics
Medical history
Conclusion and impression on admission
Diagnostic and therapeutic orders
Clinical observations
Report of relevant physical examination
Consultation reports
Diagnostic and therapeutic reports
Final diagnosis and prognosis
Discharge summary
Postmortem results
Psychological needs summary
Physical examination report
Treatment plan
Evidence of informed consents
Progress notes
Reports of surgical and invasive procedures
Records of donations and implants
Conclusions at termination of stay
Discharge info given to patient and family
Follow-up care instructions
The Joint Commission and medical records
Identify the patient
Support the diagnoses
Justify the treatment
Document the course and results
Facilitate continuity of care
Define coding
Converts diagnoses and procedures into a numerical system
Health Information Department functions
Support health services research.
Maintain records for utilization management, risk management, and quality management or performance improvement programs.
Ensure patient privacy and security issues.
Ensure compliance with legal requirements.
Perform other needed services related to patient records
Octostop immobilization device is used for?
Restraint board
Patient can be rotated 360° into eight different positions.
Radiolucent material
Durable
Limited to pediatric patients up to 1 year old
Immobilization technique used for neonates and young infants
sheet restraint
Using a sheet to “mummify” an infant, the sheet must be put into a triangle shape first
(comment)
comment
Know the use of a stockinette
Stretchable cotton fabric in the shape of a sleeve pulled over a fractured extremity before a plaster cast is applied.
Effective as a restraint when pulled over the upper or lower extremities of a child and secured with tape
Good for immobilizing the upper limbs above and behind the child’s head
Radiolucent vs radiopaque and which is ideal to use
Radiolucent - ideal - does not show up on an image
Radiopaque - shows up in an image
An inflatable air splint is used for:
lower extremity trauma
When performing a Lumbar spine Xray on the elderly:
place a sponge below the patient’s knees for comfort
Pigg-O-Stat immobilizer information
It’s evil and hopefully no longer used?
This is the torture looking device used on toddlers.
“Used for the upright chest” was the highlighted info.
Do we ever remove a C-collar
NO
Radiograph a patient in their antishock garment if:
x-raying a patient who is experiencing hemorrhagic shock
To achieve dorsiflexion of the ankle, the most effective immobilization device is:
Velcro straps
What do we do for the Radiologist when using sandbags as an immobilization device?
Ensure it is out of view
Take note that it has been used
To establish a patient rapport, the imaging professional should?
Use effective communication techniques
???
For efficient and safe patient transfers, the imaging professional should utilize ______muscles for support.
red postural
The human body’s center of gravity
is located just below the belly button, roughly in the center of the pelvis, slightly in front of the second sacral vertebra.
Patient positions:
Sims (laying on side with knee bent)
Fowlers (sitting upright)
Supine(flat on back)
Prone (flat on stomach)
When transferring patients:
always LOCK the bed/cart/chair
What is involved in a two-person lift?
Highlighted info was “ALL transfers should be initiated toward the patient’s STRONG side”
Use a ________ if patients cannot assist with a cart-to-transfer
draw sheet
In a rolling motion transfer, always:
move the patient toward you
The hydraulic lift:
always needs the sling!
Wheelchair transfers:
allow the patient to help if they can
Know good lifting mechanics
(comment)
comment
Define Orthostatic hypotension
A sudden drop in blood pressure caused by a change in a patient’s body position
Mobility vs stability muscles
Muscles of the torso are stability muscles.
Limb muscles are mobility muscles
The most common work-related injuries are?
Work-Related Musculoskeletal Disorder (WRMSD)
It is appropriate to touch the patient to clarify the area of his/her pain
(comment)
(comment)
The chief complaint
What, Duration, Where
Sacred Seven medical histories
Localization
Chronology
Quality
Severity
Onset
Aggravating or alleviating factors
Associated manifestations
Ask history questions that are open-ended and non-leading
(comment)
comment
