Transcript Recording and Reporting Patient Data
Record and Report Patient Data
3.01 Understand Diagnostic and Therapeutic Services 1
Record Patient Data
• Patient data must be recorded accurately.
• Document procedures as you do them.
• Use the proper format and appropriate forms.
• Record results in BLACK ink.
3.01 Understand Diagnostic and Therapeutic Services 2
Collect Patient Data
Patient Assessment Assessment
Objective Measurable – vital signs – weight and height – test results Disease symptoms that can be observed by somebody other than the person who is ill Subjective perceived to exist only by the patient and is not recognizable to anyone else 3.01 Understand Diagnostic and Therapeutic Services 3
Record Patient Data SOAP Notes
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S
ubjective observations: what the patient states (symptoms) •
O
bjective observations: what is seen or measured (signs) •
A
ssessment: normal versus abnormal •
P
lan: what will be done 3.01 Understand Diagnostic and Therapeutic Services 4
Record Patient Data S ubjective observations:
what the patient states (symptoms) • “My tooth hurts.” • “My jaw aches.” • “I bit my tongue.” 3.01 Understand Diagnostic and Therapeutic Services 5
Record Patient Data O bjective observations
: what is seen or measured (signs) 3.01 Understand Diagnostic and Therapeutic Services location 6
Record Patient Data
•
A ssessment
: normal versus abnormal 3.01 Understand Diagnostic and Therapeutic Services 7
Record Patient Data
•
P lan
: what will be done?
3.01 Understand Diagnostic and Therapeutic Services 8
Record Patient Data SOAP Notes
•
S
ubjective observations: what the patient states (symptoms) •
O
bjective observations: what is seen or measured (signs) •
A
ssessment: normal versus abnormal •
P
lan: what will be done 3.01 Understand Diagnostic and Therapeutic Services 9
Record Patient Data
Subjective or objective?
3.01 Understand Diagnostic and Therapeutic Services 10
Record Patient Data
Subjective or objective?
3.01 Understand Diagnostic and Therapeutic Services 11
Record Patient Data
Subjective or objective?
3.01 Understand Diagnostic and Therapeutic Services 12
Record Patient Data
Subjective or objective?
3.01 Understand Diagnostic and Therapeutic Services 13
Record Patient Data
Subjective or objective?
A B
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How would you record the following statement?
• The patient is having a seizure.
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How would you record the following statement?
• The patient is nervous.
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How would you record the following statement?
• The patient has dermatitis.
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How would you record the following statement?
• The patient is cyanotic.
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Report Patient Data
3.01 Understand Diagnostic and Therapeutic Services 19
Report Patient Data Oral reports :
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Report observations, patient results or requests to supervisor/staff prior to leaving the area.
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Report abnormal results to supervisor immediately.
Team reports Individual reports 3.01 Understand Diagnostic and Therapeutic Services 20
Report Patient Data
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Written reports : Test results or observations are relayed on the patient’s medical record The medical record is a legal document.
Information must be accurate
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Summary: Collect, Record, Report Patient Data
• Choose appropriate tool to assess patient’s treatment plan • Analyze information gathered • Evaluate patient response to treatment and/or procedure • Revise treatment plan based on information gathered • Record and report accurately, in a timely manner 3.01 Understand Diagnostic and Therapeutic Services 22