Transcript VS 1- pt information

Pearson's Comprehensive
Medical Assisting
Administrative and Clinical Competencies
Second Edition
CHAPTER
CHAPTER
35
Vital Signs
Lesson 1:
Documentation of Patient Information
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Think!
• When an error is entered into a patient’s
chart, how should this error be corrected?
What might be some dos and don’t in this
situation?
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Reasons for Maintaining the
Patient Record
• Planning patient care
• Auditing health agencies for quality
assurance information
• Gathering research data
• Educating future health care providers
• Obtaining reimbursement for services
• Providing legal documentation of care
• Analyzing health care to assist in planning
for future health care needs
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Contents of the Patient Medical
Record
• Intake or registration
information
• Medical history
• Test results
• Records from other
physicians or facilities
• Diagnosis and detailed
treatment plan
• Operative reports
• Informed consent forms
• Hospital discharge
summary
• Correspondence
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Types of Diagnoses
• Final or medical diagnosis
– Arrived at after all tests, procedures, and
examinations are complete
• Clinical diagnosis or working diagnosis
– A preliminary presumptive diagnosis made by
the physician based on the health history and
physical examination
• Differential diagnosis
– The determination of which one of several
diseases is the cause of a problem
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Steps Needed to Gather
Information for Proper Charting
• Before a patient has a physical examination or is
seen by the physician, a medical history must be
obtained
• The initial patient interview is conducted by the
medical assistant and the information gathered
becomes part of the permanent medical history
• After the initial data have been gathered, the
patient’s vital signs, height, and weight are
assessed
• The physician then examines the patient and
records the information obtained
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
The Initial Patient Interview
• Performed to obtain information on the
patient’s current and past illnesses and
treatments
• Important to ensure the patient's privacy
during the interview
• Patient should be made to feel at ease
• Appropriate types of questions should be
utilized to obtain needed information
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Steps in Interviewing a Patient
Step 6: Provide privacy during the
interview.
Step 5: Use an “icebreaker” comment to
put patient at ease.
Step 4: Ask the patient’s permission to interview
him/her.
Step 3: Be professional at all times.
Step 2: Greet patient by name and provide your name.
Step 1: Review patient’s chart before the interview.
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Steps in Interviewing a Patient
Step 12: Document according to
facility policy.
Step 11: Summarize important points.
Step 10: Treat sensitive topics with respect.
Step 9: Avoid providing medical assurances.
Step 8: Avoid making judgmental responses.
Step 7: Be aware of verbal and nonverbal cues.
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Charting Guidelines
• Date and time every entry (while timing may
not be required in the medical office, it is in
hospital and ambulatory care settings)
• Write legibly
• Use permanent dark ink
• Use medical terminology and accepted
abbreviations
• Use correct spelling
• Sign every entry
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Charting Guidelines
• Accurately document information (stick to
facts not opinion)
• Document the proper sequence in which
events occurred
• Document appropriate information
concerning health and care given
• Be concise
• Correct errors only by drawing a single line
through the incorrect entry and initialing it –
Then record the corrected entry
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Correcting a Charting Error
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Six Cs of Charting
• Client’s own words used exactly and in quotes
• Clarity must be achieved when recording
information
• Completeness is essential
• Conciseness of entries saves time and chart
space
• Chronological order of information is critical
• Confidentiality of patient information is
mandatory
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Measuring Weight and Height
• Called anthropometric
measurements
• Can provide important
information related to the
patient’s general health
• Frequent weight
monitoring is particularly
important for:
–
–
–
–
Diabetic patients
Pregnant women
Cardiac patients
Patients with eating
disorders
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Obtaining a Patient’s Weight
• Important to provide
patient privacy
• Typically done with
clothing on
• Shoes should be
removed
• May need to convert
information from pounds
to kilograms or kilograms
to pounds
• Patients who cannot
stand may be weighed on
a chair or bed scale
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Converting Kilograms to Pounds
To Convert Kilograms to Pounds (kg to lb)
1 kilogram (kg) = 2.2 pounds (lbs)
Multiply the number of kilograms by 2.2 lbs.
Example: If a patient weighs 64 kilograms,
Multiply 64 by 2.2.
64 X 2.2 = 140.8 or 141 pounds
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Converting Pounds to Kilograms
To Convert Pounds to Kilograms (lb to kg)
1 pound = 0.45 kilograms
Multiply the number of pounds by 0.45.
Example: If a patient weighs 130 pounds,
multiply 130 by 0.45.
130 X 0.45 = 58.5 or 59 kilograms
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Measuring a Patient’s Height
• Measured without shoes
• Heel, buttocks, and back of head should be
touching the measuring stick or bar
• L-shaped arm is raised or lowered to rest on
top of head
• Height can be recorded in inches and feet or
centimeters
– Convert inches and feet to centimeters by multiplying
by 2.5
– Convert from centimeters to inches by dividing by 2.5
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Questions?
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.