Post on 29-Jul-2015
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Record and ReportRecord and ReportPatient DataPatient Data
3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Record Patient DataRecord 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.
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Collect Patient DataCollect Patient DataPatient AssessmentPatient Assessment
AssessmentAssessmentObjective
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
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3.01 Understand Diagnostic and Therapeutic Services
Record Patient DataRecord Patient DataSOAPSOAP Notes Notes
• SSubjective observations: what the patient states (symptoms)
• OObjective observations: what is seen or measured (signs)
• AAssessment: normal versus abnormal
• PPlan: what will be done
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3.01 Understand Diagnostic and Therapeutic Services
Record Patient DataRecord Patient Data
Subjective observations: what the patient states
(symptoms)
• “My tooth hurts.”
• “My jaw aches.”
• “I bit my tongue.”
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3.01 Understand Diagnostic and Therapeutic Services
Record Patient DataRecord Patient Data
Objective observations: what is seen or measured (signs)
coloramount or size
temperature
blood pressure location
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3.01 Understand Diagnostic and Therapeutic Services
Record Patient DataRecord Patient Data
• Assessment:
normal versus abnormal
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3.01 Understand Diagnostic and Therapeutic Services
Record Patient DataRecord Patient Data
• Plan: what will be done?
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3.01 Understand Diagnostic and Therapeutic Services
Record Patient DataRecord Patient DataSOAPSOAP Notes Notes
• SSubjective observations: what the patient states (symptoms)
• OObjective observations: what is seen or measured (signs)
• AAssessment: normal versus abnormal
• PPlan: what will be done
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3.01 Understand Diagnostic and Therapeutic Services
Record Patient Data Record Patient Data
Subjective or objective?Subjective or objective?
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3.01 Understand Diagnostic and Therapeutic Services
Record Patient Data Record Patient Data
Subjective or objective?Subjective or objective?
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3.01 Understand Diagnostic and Therapeutic Services
Record Patient Data Record Patient Data
Subjective or objective?Subjective or objective?
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3.01 Understand Diagnostic and Therapeutic Services
Record Patient Data Record Patient Data
Subjective or objective?Subjective or objective?
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3.01 Understand Diagnostic and Therapeutic Services
Record Patient Data Record Patient Data
Subjective or objective?Subjective or objective?
A B
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3.01 Understand Diagnostic and Therapeutic Services
How would you record the How would you record the following statement?following statement?
• The patient is having a seizure.
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3.01 Understand Diagnostic and Therapeutic Services
How would you record the How would you record the following statement?following statement?
• The patient is nervous.
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3.01 Understand Diagnostic and Therapeutic Services
How would you record the How would you record the following statement?following statement?
• The patient has dermatitis.
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3.01 Understand Diagnostic and Therapeutic Services
How would you record the How would you record the following statement?following statement?
• The patient is cyanotic.
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Report Patient DataReport Patient Data
3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Report Patient DataReport Patient DataOral reports:
– Report observations, patient results or requests to supervisor/staff prior to leaving the area.
– Report abnormal results to supervisor immediately.
Individual reports
Team reports
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3.01 Understand Diagnostic and Therapeutic Services
Report Patient DataReport Patient Data
Written reportsWritten 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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3.01 Understand Diagnostic and Therapeutic Services
Summary:Summary:Collect, Record, Report Collect, Record, Report
Patient DataPatient 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
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