Understanding Health Science Standards

DIAGNOSTIC AND THERAPEUTIC SERVICE

PATIENT CARE PROCESS

PATIENT INTERVIEWS

What Are Diagnostic Services?

•Diagnostic Service professionals create a picture of the health status of patients at a single point in time.

What Are Therapeutic Services?

•Therapeutic Service professionals change the health status of the patient over a period of time.

PATIENT CARE PROCESS

Responsibilities of Diagnostic and Therapeutic Services: Patient Care Process

• Assessing the Patient

• Creating a Plan of Care for the Patient Based Upon the Assessment

• Implementing the Patient Plan of Care

• Evaluating the Patient Plan of Care

Assessing the Patient

• Health History and Patient Interview

• Physical Assessment (e.g. Vital Signs)

• Record all findings (all subjective and objective data)

Plan Patient Care

• Work within scope of practice for career area

• Determine if a request is appropriate for patient

• Include patient in plan of care

• Develop a plan to meet patient’s needs

• Assemble appropriate materials

Implement Patient Care

• Check physician’s order• Verify patient identification• Evaluate for contraindications• Obtain patient’s consent • Properly prepare patient• Perform care in an orderly manner• Perform procedure according to standards• Use equipment as recommended by manufacturer • Monitor patient’s condition throughout procedure• Modify care as required for patient

Evaluate Patient Care

• Patient response to treatment and/or procedure• Implementation of the procedure• Function of equipment• Personal performance• Analysis of information gathered• Revision of treatment plan based on information gathered

***Evaluation is a continual process***

PATIENT INTERVIEW

Patient Interview

•Completed on admission to a health care facility• In-patient facility• Outpatient facility

•Prepare for the patient:• Room is neat • Supplies are available• Review the patient’s chart to anticipate patient needs

Parts of the Patient Interview

• Demographic Data

• Financial Information

• Privacy Information

• Release of Information

• Medical History

Demographic Data

• Patient’s full name• Address• Mailing address, if different• Telephone number

• home

• work

• Date of birth• Social security number• Insurance information• Emergency contact person

Privacy Information

HIPPA - Privacy rule limiting the release of patient information

Information given to patient must include:• Statement of patient rights

• Facility’s practices related to privacy

• Where and how to file a complaint

**Receipt of information must be signed by patient.**

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

Medical/Health History

• Chief complaint/Reason for Seeking Care

• Present illness

• Past Medical history

• Family history

• Social history

• Review of systems

Medical/Health History: Chief Compliant “CC”

• A subjective statement made by a patient describing the most significant or serious symptoms or signs of illness or dysfunction that caused him or her to seek health care.

• EX) CC: “I have cough that has lasted several days”

• The chief compliant is always in quotes in the patient’s exact words

Present Illness

• An account obtained during the interview with the patient of the onset, duration, and character of the present illness, as well as of any acts or factors that aggravate or ameliorate the symptoms. The patient is asked what he or she considers to be the cause of the symptoms and whether a similar condition has occurred in the past.

**OLDCART**

O-Onset

L-Location

D-Duration

C-Characteristics

A-Aggravating Factors

R-Relieving Factors

T-Timing/Treatment

Present Illness: Pain Assessment

***PQRST***

• P-Provokes•Q-Quality (sharp, dull, stabbing)• R-Radiates• S-Severity (scale 0-10)• T-Timing (start, how long it lasts)

Past Medical History

• Childhood Illnesses• Accidents or Injuries• Serious or Chronic Illness• Hospitalizations• Operations• Obstetric History• Immunizations• Last Examination Date• Allergies• Current Medication

Family History

• Ask about the age and health or the age and cause of death of blood relatives, such as parents, grandparents, and siblings

• Specifically ask about family history of heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease and tuberculosis.

• Construct a family tree or genogram to show the information clearly and concisely

Social History

• Includes the following:• Living arrangements

• Occupation

• Marital status

• Number of children

• Drug use (including tobacco, alcohol, other recreational drug use)

• Recent foreign travel

• Exposure to environmental pathogens through recreational activities

• Pets.

Review of Systems

• Purpose:• To evaluate the past and present health state of each body system

• To double-check in case any significant data were omitted in the present illness section

• To evaluate health promotion practices

**The order of the examination of body system questions are head-to-toe**

Review of Systems: General

•Weight loss or gain

• Fatigue

• Fever or chills

•Weakness

• Trouble sleeping

Review of Systems: Skin

• Rashes

• Lumps

• Itching

• Dryness

• Color Change

• Change in Hair or Nails

Review of Systems: HEENT

• Head: headache, head injury

• Eyes: Vision, Glasses or contact lenses, Last eye exam, Pain, Redness, Double vision, Blurred vision, Flashing lights, Glaucoma, Cataracts

• Ears: Decreased hearing, Tinnitus, Earache, Discharge

• Nose: Stuffiness, Discharge, Itching, Hay fever, Nosebleeds, Sinus pain

• Throat/Mouth: Condition of teeth, Bleeding gums, Dentures, Last dental exam, Sore tongue, Dry mouth, Sore throats, Hoarseness

Review of Systems: Neck

• Lumps

• Swollen glands

• Goiter (large thyroid)

• Pain

• Stiffness

Review of Systems: Breasts

• Lumps

• Pain

• Discharge

• Self breast exams

• Nursing a child

Review of Systems: Respiratory

• Cough

• Sputum color and amount

• Hemoptysis

• Dyspnea

•Wheezing

• Painful breathing

• Exposure to tuberculosis

Review of Systems: Cardiovascular

• Chest pain or tightness

• Palpitations

• Dyspnea

• Orthopnea

• Paroxysmal nocturnal dyspnea

• Edema

Review of Systems: Gastrointestinal

• Trouble swallowing• Heartburn• Loss of appetite• Nausea• Change in bowel habits• Blood in stool• Dark tarry stools• Constipation• Diarrhea• Abdominal pain• Jaundice

Review of Systems: Urinary

• Frequency of urination

• Nocturia

• Urgency

• Burning or pain

• Hematuria

• Infections

• Kidney stones

• Incontinence

• Hesitancy

Review of Systems: Genitals

• Male:• Hernia• Penile discharge• Sores• Testicular mass or pain• Erectile dysfunction• Condom use• STDs

• Female:• Periods• Onset, length,

frequency, duration• Dysmenorrhea• Pregnancies• Vaginal discharge, itching

or rashes• STDs• Birth Control

Review of Systems: Vascular

• Leg cramps

• Varicose veins

• Blood clots

Review of Systems: Musculoskeletal

• Muscle or joint pains

• Stiffness

• Gout

• Back pain

• Swelling of joints

• Timing of symptoms

• Trauma

Review of Systems: Neurologic

• Dizziness

• Lightheadedness

• Fainting

• Seizures

•Weakness, paralysis

• Numbness

• Tingling

• Tremor

Review of Systems: Endocrine

• Heat or cold intolerance

• Excessive sweating

• Polyuria

• Polydypsia

• Change in glove or shoe size

Review of Systems: Psychiatric

• Nervousness

• Depressed mood

• Memory loss

• Stress

• Disturbing thoughts