Collecting Patient Data 3.01 Understand Diagnostic and Therapeutic Services 1

Collect Patient Data Patient Interview Completed on admission to a health care facility Completed on admission to a health care facility In-patient facility In-patient facility Outpatient facility Outpatient facility Prepare for the patient: Prepare for the patient: Room is neat Room is neat Supplies are available Supplies are available Review the patient’s chart Review the patient’s chart to anticipate patient needs 3.01 Understand Diagnostic and Therapeutic Services 2

Collect Patient Data Patient Interview Demographic data Patient’s full name Patient’s full name Address Address Mailing address, if different Mailing address, if different Telephone number Telephone number home home work work Date of birth Date of birth Social security number Social security number Insurance information Insurance information Emergency contact person Emergency contact person 3.01 Understand Diagnostic and Therapeutic Services 3

Collect Patient Data Patient Interview Financial information Financial policy of the practice Billing Billing Insurance billing Insurance billing Co-payments Co-payments Finance charges Finance charges 3.01 Understand Diagnostic and Therapeutic Services 4

Collect Patient Data Patient Interview Privacy information HIPPA - Privacy rule limiting the release of patient information Information given to patient must include: Statement of patient rights Statement of patient rights Facility’s practices related to privacy Facility’s practices related to privacy Where and how to file a Where and how to file a complaint complaint Receipt of information must be signed by patient Understand Diagnostic and Therapeutic Services 5

Collect Patient Data Patient Interview Release of information To request information from previous providers to obtain past medical records To allow sharing of information with family members at patient’s request 3.01 Understand Diagnostic and Therapeutic Services 6

Collect Patient Data Patient Interview Medical history Chief complaint – why they came i.e. abdominal pain Chief complaint – why they came i.e. abdominal pain Present illness Present illness Medical history Medical history Family history Family history Social history Social history Review of systems Review of systems 3.01 Understand Diagnostic and Therapeutic Services 7

Collect Patient Data Patient Interview Obtain Medical History Activity 3.01 Understand Diagnostic and Therapeutic Services 8

Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services 9

Collect Patient Data Patient Assessment AssessmentObjective Measurable Measurable vital signs vital signs weight and height weight and height test results test results Disease symptoms that can be observed by somebody other than observed by somebody other than the person who is ill the person who is ill Subjective Subjective perceived to exist only by the perceived to exist only by the patient and is not recognizable to anyone else patient and is not recognizable to anyone else 3.01 Understand Diagnostic and Therapeutic Services 10

Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services 11

Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services 12

Collect Patient Data Patient Assessment What the health care professional can: See (observation) See (observation) Smell Smell Touch (palpation) Touch (palpation) Hear (auscultation, percussion) Hear (auscultation, percussion) 3.01 Understand Diagnostic and Therapeutic Services 13

Collect Patient Data Patient Assessment See (observe) What do you see? 3.01 Understand Diagnostic and Therapeutic Services 14

Collect Patient Data Patient Assessment SMELL What do you smell? unusual odors unusual odors body body breath breath wounds wounds body fluids body fluids 3.01 Understand Diagnostic and Therapeutic Services 15

Collect Patient Data Patient Assessment TOUCH What do you feel? pulse pulse warm/cold warm/cold wet/dry wet/dry soft/firm soft/firmpalpation use the hands to determine size, shape, location, and firmness of the internal organs 3.01 Understand Diagnostic and Therapeutic Services 16

Collect Patient Data Patient Assessment Percussion – method of tapping on body areas to determine the shape, size, and/or density of underlying structures. Used to assess the chest or abdomen. Requires skill in touch and listening to the nature of the sound. Percussion – method of tapping on body areas to determine the shape, size, and/or density of underlying structures. Used to assess the chest or abdomen. Requires skill in touch and listening to the nature of the sound Understand Diagnostic and Therapeutic Services 17

Collect Patient Data Patient Assessment HEAR What do you hear? body sounds body sounds speech speech breathing breathing laughter/crying laughter/crying Auscultation- listening to internal body sounds, usually with a stethoscope 3.01 Understand Diagnostic and Therapeutic Services

Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services 19 Activity

Collect Patient Data Patient Assessment

Ophthalmoscope used to examine the eyes 3.01 Understand Diagnostic and Therapeutic Services 21

Collect Patient Data Patient Assessment Otoscope used to examine the ears 3.01 Understand Diagnostic and Therapeutic Services 22

Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services 23 Penlight used to determine pupil size/reaction

Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services 24 Reflexhammer used to test reflexes

Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services 25 Scales used to measure weight Wheelchair scale Mechanical lift with a scale Balance-beam scale Baby scale

Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services 26 Sphygmomanometer used to measure blood pressure

Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services 27 Stethoscope used to listen to internal body sounds

Collect Patient Data Patient Assessment 3.01 Understand Diagnostic and Therapeutic Services 28 Non-mercury glass thermometer Electronic thermometer Aural thermometer Thermometer used to measure heat Digital thermometer