Paramedic Care: Principles & Practice. Volume 2 Patient Assessment

Size: px
Start display at page:

Download "Paramedic Care: Principles & Practice. Volume 2 Patient Assessment"

Transcription

1 Paramedic Care: Principles & Practice Volume 2 Patient Assessment

2 Chapter 1 The History

3 Topics Establishing Patient Rapport The Comprehensive Patient History Special Challenges

4 The Interview In the majority of medical interviews, field diagnosis is based on history. It is conducted simultaneously with the physical exam. It is a structured, flexible, tool with several components. Patient condition dictates length and completeness.

5 Establishing Patient Rapport

6 Establishing Patient Rapport Situation, the patient, and conditions will determine ability to establish rapport. Respond to the patient with empathy to gain trust. Patient s response to questions will guide the exam.

7 Establishing Patient Rapport Setting the Stage In a healthcare facility, if a patient s chart is available, review it before interviewing the patient. Gather information from the first responder personnel. Reconfirm information. Maintain an open mind!

8 If the patient cannot provide useful information, gather it from family or bystanders.

9 Establishing Patient Rapport The First Impression Your appearance should suggest neatness, cleanliness, pride, and professionalism. Present yourself as a caring, competent, and confident health care professional. Your voice, body language, gestures, and especially eye contact should communicate that you care about your patient s problems.

10 Establishing Patient Rapport Introductions Make eye contact with your patient and maintain it as you conduct the interview. Use your patient s name frequently during the interview. Avoid slang terms such as honey, chief, pops, or sweetie. Be aware of other forms of nonverbal communication.

11 Establishing Patient Rapport Asking Questions Ask questions in a way that elicits accurate information from your patient. Use a combination of open-ended and closedended questions. Open-ended questions allow patient to explain how he/she feels. Closed-ended questions elicit short answers.

12 Establishing Patient Rapport Language and Communication Effective communication means connecting with your patient. Barriers to communication include: Cultural differences Language differences Deafness Speech impediments Blindness When encountering communication barriers, try to enlist someone to help.

13 Establishing Patient Rapport Active listening techniques: Facilitation Reflection Clarification Empathy Confrontation Interpretation Asking about feelings

14 Establishing Patient Rapport Sensitive Topics A paramedic must learn to become comfortable dealing with sensitive topics. Sensitive topics may include sexual activities, death and dying, physical deformities, bodily functions, and domestic violence.

15 Establishing Patient Rapport Sensitive Topics Familiarize yourself with and practice some opening questions on sensitive topics. It is critical that you remain calm, objective, and nonjudgmental.

16 The Comprehensive Patient History

17 Preliminary Data Always record the date and time of the physical exam. Determine your patient s age, sex, race, birthplace, and occupation. These questions provide a starting point for the interview. After you have gathered the information, you should establish its reliability.

18 The Chief Complaint Begin with an open-ended question about your patient s chief complaint. The chief complaint is the pain, discomfort, or dysfunction that caused the patient to request help. When possible, report and record the chief complaint in the patient s own words.

19 The Present Illness OPQRST-ASPN Onset of the problem Provocative/ Palliative factors Quality Region/Radiation Severity Time Associated Symptoms Pertinent Negatives

20 Past History Ask questions about the patient s general state of health, childhood and adult diseases, psychiatric illnesses, accidents or injuries, surgeries, and hospitalizations. The patient s condition, the situation, and time constraints will determine how much information you can and should gather on the scene.

21 Current Health Status Current medications Allergies Tobacco Alcohol, drugs, and related substances Diet Screening tests Immunizations

22 Current Health Status Sleep patterns Exercise and leisure activities Environmental hazards Use of safety measures Family history Home situation and significant others Daily life

23 Current Health Status Important exercises Religious beliefs The patient s outlook

24 You should take your patient s medications with you to the hospital, when practical.

25 Review of Systems A system-by-system series of questions designed to identify problems your patient has not already identified: Skin Head Eyes Ears Nose Mouth/Throat Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal Neurologic Psychologic Endocrine Hematologic

26 Special Challenges

27 Special Challenges Silence Overly talkative patients Multiple symptoms Anxiety Depression Sexually attractive or seductive patients Confusing behaviors or symptoms

28 Special Challenges Patients needing reassurance Anger and hostility Intoxication Crying Limited intelligence Language barriers Hearing problems Blindness Talking with families or friends

29 Summary Establishing Patient Rapport The Comprehensive Patient History Special Challenges

Documenting & Coding for Compliance

Documenting & Coding for Compliance Documenting & Coding for Compliance Department of Family and Community Medicine October 17, 2012 UNMMG Compliance Documentation Documentation Why is it important? Enables the physician and other health

More information

Patient Assessment. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Patient Assessment. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Patient Assessment Holistic Care Holistic care includes assessing the patient s health status with physical, cognitive, psychosocial, and behavioral data. A comprehensive patient care that considers the

More information

A Guide to Compliance at New York City s Health and Hospitals Corporation Resident Orientation

A Guide to Compliance at New York City s Health and Hospitals Corporation Resident Orientation A Guide to Compliance at New York City s Health and Hospitals Corporation Resident Orientation 1 General Principles of Documentation 2 7 General Principles of Documentation 1. Medical record should be

More information

PATIENT INFORMATION. Address: Sex: City: State: address: Cell Phone: Home Phone: Work Phone: address: Cell Phone:

PATIENT INFORMATION. Address: Sex: City: State:  address: Cell Phone: Home Phone: Work Phone:  address: Cell Phone: PATIENT INFORMATION Name: _ DOB: _ Age: Address: _Sex: City: _ State: _ Zip: _ Email address: Cell Phone: _ Home Phone: Work Phone: _ Responsible Party (if different from above) Name: DOB: Address: E-mail:

More information

E & M Coding. Welcome To The Digital Learning Center. Today s Presentation. Course Faculty. Beyond the Basics. Presented by

E & M Coding. Welcome To The Digital Learning Center. Today s Presentation. Course Faculty. Beyond the Basics. Presented by Welcome To The Digital Learning Center Presented by Your Partner In Building High Performance Practices Today s Presentation E & M Coding Beyond the Basics Course Faculty R. Thomas (Tom) Loughrey, MBA,

More information

Start with the Problem

Start with the Problem Start with the Problem Jen Godreau, BA, CPC, CPEDC Director of Development & Operations Supercoder.com jenniferg@supercoder.com December 2011 Phone: (866)-228-9252 E-Mail: customerservice@supercoder.com

More information

E/M: Coding Opportunities- Documentation is key

E/M: Coding Opportunities- Documentation is key E/M: Coding Opportunities- Documentation is key Compiled and Presented by: Suzan Berman CPC, CEMC, CEDC The duplication of this presentation, all or in part, without the expression permission of the presenter,

More information

Certified Clinical Chiropractic Assistants. Required Clinical Competencies DRAFT

Certified Clinical Chiropractic Assistants. Required Clinical Competencies DRAFT Certified Clinical Chiropractic Assistants DRAFT Required Clinical Competencies DRAFT The Certified Clinical Chiropractic Assistant (CCCA) program is designed to enhance the safe and effective application

More information

SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely)

SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely) SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely) Name: Former/ Maiden Name: Date of Birth: Age: Today s Date: *Language: Race: Ethnicity: *Do

More information

Personal Support Worker

Personal Support Worker PROGRAM OBJECTIVES The Personal Support Worker program prepares students to deliver appropriate short or longterm care assistance and support services in either a long-term care facility, acute care facility,

More information

Lake Mary Eye Care Adult Form

Lake Mary Eye Care Adult Form Lake Mary Eye Care Adult Form Today s Date Last First MI Street City State Zip Code Home Phone Work Phone Cell Phone Email Address Date of Birth Age Patient s SSN Sex: M F Employer Occupation Marital Status:

More information

Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country

Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country Hoover Hearing Clinic A division of Hoover ENT Hoover, Alabama 35244 205-733-9694 Tel PATIENT INFORMATION ACCOUNT # DATE MD NEW UPDATE Patient s Full Name DOB Age Patient s SSN Sex: Male Female Preferred

More information

Welcome to our office! Please fill out this form as completely as possible and return it to the desk.

Welcome to our office! Please fill out this form as completely as possible and return it to the desk. Welcome to our office! Please fill out this form as completely as possible and return it to the desk. Name of Doctor you wish to see: Today's Date Name Email Address Address Home Male Female Cell City

More information

Goal #1: Mastery of Clinical Knowledge with Integration of Basic Sciences

Goal #1: Mastery of Clinical Knowledge with Integration of Basic Sciences Goal #1: Mastery of Clinical Knowledge with Integration of Basic Sciences Objective #1: To demonstrate comprehension of core basic science knowledge 1.1a) demonstrate knowledge of the basic principles

More information

Chapter 59. Learning Objectives 9/11/2012. Putting It All Together

Chapter 59. Learning Objectives 9/11/2012. Putting It All Together 1 Chapter 59 Putting It All Together 2 Learning Objectives Discuss how assessment based management contributes to effective patient and scene assessment. Describe factors that affect assessment and decision

More information

Evaluation and Management

Evaluation and Management Evaluation and Management CPT CPT copyright 2011 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by

More information

Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name

Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name *SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code

More information

Chapter 11 Assessment of the Medical Patient DOT Directory

Chapter 11 Assessment of the Medical Patient DOT Directory Chapter 11 Assessment of the Medical Patient U.S. Objectives U.S. Objectives are covered and/or supported by the PowerPoint Slide Program and Notes for Emergency Care, 11th Ed. Please see the Chapter 11

More information

Health Assessment Student Handbook

Health Assessment Student Handbook Health Assessment Student Handbook Fall 2017 Your guide to the Shadow Health Digital Clinical Experience UGV.1 Table of Contents WELCOME!... 3 HEALTH HISTORY Instructions... 4 HEENT Instructions... 5 RESPIRATORY

More information

PATIENT AGGRESSION & VIOLENCE BEST PRACTICES NCQC PSO Safe Table July 2015

PATIENT AGGRESSION & VIOLENCE BEST PRACTICES NCQC PSO Safe Table July 2015 PATIENT AGGRESSION & VIOLENCE BEST PRACTICES NCQC PSO Safe Table July 2015 Minimize the impact of patient aggression and violence by focusing on various phases of the care process. RECOGNITION Understand

More information

Test Content Outline Effective Date: February 9, Pediatric Primary Care Nurse Practitioner Board Certification Examination

Test Content Outline Effective Date: February 9, Pediatric Primary Care Nurse Practitioner Board Certification Examination Board Certification Examination There are 200 questions on this examination. Of these, 175 are scored questions and 25 are pretest questions that are not scored. Pretest questions are used to determine

More information

WEEK DAY LECTURE SUBJECTS CLASS HOURS ORIENTATION. Course Logistics: breaks; schedule etc.

WEEK DAY LECTURE SUBJECTS CLASS HOURS ORIENTATION. Course Logistics: breaks; schedule etc. WEEK DAY LECTURE SUBJECTS CLASS HOURS 1 1 ORIENTATION Course Logistics: breaks; schedule etc. Course Overview: review syllabus, assignment, quizzes, recitation NCLEX Test plan and format; How to study;

More information

SKILLS CHECKLIST FOR RECERTIFICATION

SKILLS CHECKLIST FOR RECERTIFICATION NAME 2012 CBT 434-EMT12 Cardiovascular Emergencies EMERGENCY MEDICAL SERVICES (11/22/2011) MH PRINT STUDENT S NAME SKILLS CHECKLIST FOR RECERTIFICATION ID # DATE Objective: Given a partner, appropriate

More information

PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!

PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU! PATIENT INFORMATION FORM PATIENT DATA: - - PATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY # SEX ( ) - ( ) - ADDRESS HOME PHONE NUMBER MOBILE PHONE NUMBER CITY STATE ZIP CODE OCCUPATION / / DATE OF

More information

How to Write a Medical Note for the. Foundations of Doctoring Course and Beyond: Demystifying the Focused (SOAP) Note

How to Write a Medical Note for the. Foundations of Doctoring Course and Beyond: Demystifying the Focused (SOAP) Note How to Write a Medical Note for the Foundations of Doctoring Course and Beyond: Demystifying the Focused (SOAP) Note and the Comprehensive (H&P) Note by Todd Guth, MD Overview of the Medical Note Medical

More information

Early and Periodic Screening, Diagnosis and Treatment

Early and Periodic Screening, Diagnosis and Treatment Early and Periodic Screening, Diagnosis and Treatment 1 Healthchek Ohio Medicaid EPSDT Services Early Periodic Screening Diagnosis Treatment Identify problems early, starting at birth Check children s

More information

Wilkins: Clinical Assessment in Respiratory Care, 6 th Edition

Wilkins: Clinical Assessment in Respiratory Care, 6 th Edition Wilkins: Clinical Assessment in Respiratory Care, 6 th Edition Chapter 1: Preparing for the Patient Encounter Test Bank MULTIPLE CHOICE 1. Which of the following activities is not part of the role of respiratory

More information

SMALL GROUP SESSION 6A September 22 nd or September 24 th

SMALL GROUP SESSION 6A September 22 nd or September 24 th SMALL GROUP SESSION 6A September nd or September 4 th Hospital Interviews (Chief Complaint, History of Present Illness, Past Medical History and Social History) Suggested Readings: The Medical Interview,

More information

The World of Evaluation and Management Services and Supporting Documentation

The World of Evaluation and Management Services and Supporting Documentation The World of Evaluation and Management Services and Supporting Documentation Presented by Cahaba Government Benefit Administrators, LLC Provider Outreach and Education May 14, 2009 Disclaimers Disclaimer

More information

New Patient Registration Form NJR_NP_F100

New Patient Registration Form NJR_NP_F100 New Patient Registration Form NJR_NP_F100 Patient Last Name First Name Middle Name Maiden Name Address (Street or Box) City State Zip Code Home Phone Number Cell Phone Number Work Phone Number E-Mail Patient

More information

NAPERVILLE SENIOR CENTER MEMBER INFORMATION

NAPERVILLE SENIOR CENTER MEMBER INFORMATION NAPERVILLE SENIOR CENTER MEMBER INFORMATION Member Name: Address: City: SSN: Long Term Insurance: DOB: Home Phone: Cell Phone: Zip: Email Address: Other Entitlement (specify): Living Arrangement: Alone

More information

Library of Congress Cataloging-in-Publication Data

Library of Congress Cataloging-in-Publication Data Library of Congress Cataloging-in-Publication Data Names: Reinisch, Courtney, editor. Nursing Knowledge Center, publisher. Title: Family nurse practitioner review and resource manual / edited by Courtney

More information

PATIENT INFORMATION SHEET:

PATIENT INFORMATION SHEET: PATIENT INFORMATION SHEET: LAST NAME: FIRST NAME/MI: ADDRESS: CITY: STATE: ZIP CODE: SOCIAL SECURITY #: HOME: CELL: WORK: SEX: M F BIRTHDATE: MARITAL STATUS: SINGLE MARRIED WIDOWED OTHER EMPLOYER NAME:

More information

Fundamentals/Geriatrics Lesson: 1 Title: Introducing the Older Person Time: N/A PLAN OF LESSON OBJECTIVES

Fundamentals/Geriatrics Lesson: 1 Title: Introducing the Older Person Time: N/A PLAN OF LESSON OBJECTIVES Lesson: 1 Title: Introducing the Older Person Implementation: Linton, Ch. 11; Lecture; Power Point Presentation; Class Discussion; Transparencies 1. Define old age. 2. Describe the role of the gerontological

More information

MISSION, VISION AND GUIDING PRINCIPLES

MISSION, VISION AND GUIDING PRINCIPLES MISSION, VISION AND GUIDING PRINCIPLES MISSION STATEMENT: The mission of the University of Wisconsin-Madison Physician Assistant Program is to educate primary health care professionals committed to the

More information

What is a professional day? Boston Children s Hospital Community Education Initiative

What is a professional day? Boston Children s Hospital Community Education Initiative + Boston Children s Hospital Community Education Initiative Sponsored by Medicine Patient Services + What is a professional day? Many school systems have days during the school year for professional education

More information

Produced by The Kidney Foundation of Canada

Produced by The Kidney Foundation of Canada 85 PEACE OF MIND You have the right to make decisions about your own treatment, including the decision not to start or to stop dialysis. Death and dying are not easy things to talk about. Yet it s important

More information

Chapter 12. History Taking. Objectives. Patient History Process

Chapter 12. History Taking. Objectives. Patient History Process Chapter 12 History Taking Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1 Objectives 1. Describe the role of the radiologic technologist

More information

Allens Training Phone or

Allens Training Phone or Student Information Course Name Course code Contact details In Partial completion of Description of this unit against the qualification Descriptor What is covered in the course Employability Skills Pre-requisites

More information

Module One. EMT Transition to the new National Education Standards. Objectives: Objectives cont. Objectives cont. Objectives cont.

Module One. EMT Transition to the new National Education Standards. Objectives: Objectives cont. Objectives cont. Objectives cont. Transition to the New National EMS Education Standards: EMT-B B to EMT Module One Objectives: Upon completion, each participant will do the following to a degree of accuracy that meets the Ntl EMS Education

More information

Calculating E&M codes & 2018 Medicare Physician Fee Schedule Proposed Rule. Grace Wilson, RHIA

Calculating E&M codes & 2018 Medicare Physician Fee Schedule Proposed Rule. Grace Wilson, RHIA Calculating E&M codes & 2018 Medicare Physician Fee Schedule Proposed Rule Grace Wilson, RHIA Objectives 2018 Medicare Physician Fee Schedule E/M Coding Overview Documentation Examples Proposed Documentation

More information

NEW YORK STATE MEDICAID PROGRAM NURSE PRACTITIONER PROCEDURE CODES

NEW YORK STATE MEDICAID PROGRAM NURSE PRACTITIONER PROCEDURE CODES NEW YORK STATE MEDICAID PROGRAM NURSE PRACTITIONER PROCEDURE CODES Table of Contents GENERAL INFORMATION 2 STATE DEPARTMENT OF HEALTH CONDITIONS FOR PAYMENT 3 PRACTITIONER SERVICES PROVIDED IN HOSPITALS

More information

Sec Disconnect Go to End Forward Sec Next Report Go To

Sec Disconnect Go to End Forward Sec Next Report Go To Effective 3/15/04 escription DICTATION SYSTEM FOR INPATIENT HISTORY & PHYSICALS, DISCHARGE SUMMARIES, DELIVERY (NORMAL) NOTES OPERATIVE REPORTS DIAL 3-4000 LISTEN FOR VERBAL PROMPTS. ENTER: First 5 digits

More information

NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES

NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES Table of Contents GENERAL INFORMATION... 3 SERVICES PROVIDED IN ARTICLE 28 FACILITIES... 4 MMIS MODIFIERS... 4 MEDICINE SECTION... 7 GENERAL INFORMATION

More information

Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:

Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #: 5002 Highway 39 N Bldg. A Meridian, MS 39301 Phone: 601-512-0500 Fax: 601-512-0505 Patient Information Patient: Gender: Male Female First Middle Last Primary Language: English Spanish Other Mailing Address:

More information

District 186: High School Health Education Syllabus

District 186: High School Health Education Syllabus District 186: High School Health Education Syllabus Philosophy Statement: Health Education is a very important part of a high school students educational experience. Many students in high school do not

More information

UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences-FA11- McBane 1

UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences-FA11- McBane 1 Taking Histories and Writing SOAP Notes History Sarah McBane, PharmD, CDE, BCPS September 28, 2011 www.school.discoveryeducation.com What is History? What is History? A chronological record of significant

More information

Middle Initial: Street Address: City: Date of Birth: Age: Marital Status: Occupation: Employer: Name of Spouse: Emergency Contact:

Middle Initial: Street Address: City: Date of Birth: Age: Marital Status: Occupation: Employer: Name of Spouse: Emergency Contact: SALT LAKE EYE ASSOCIATES, LLC (801) 281-2020 1025 E 3300 S, SLC, Utah * Patient Information Sheet First Name: Last Name: Middle Initial: Referred By Family Doctor EMAIL Street Address: City: State: Zip:

More information

PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.

PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: 516-354-8597 ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. THANK YOU - 1 - NEW PATIENT MEDICAL INFORMATION Steven J.

More information

May Family Chiropractic Health Information and Health History Patient Name: Gender: Male Female

May Family Chiropractic Health Information and Health History Patient Name: Gender: Male Female 1 Health Information and Health History Patient Name: Gender: Male Female Marital Status: (Circle one) M S D W Other: Date of Birth / / Spouse Name: How many children: Patient Social Security Number: -

More information

NEW YORK STATE MEDICAID PROGRAM NURSE PRACTITIONER PROCEDURE CODES

NEW YORK STATE MEDICAID PROGRAM NURSE PRACTITIONER PROCEDURE CODES NEW YORK STATE MEDICAID PROGRAM NURSE PRACTITIONER PROCEDURE CODES Table of Contents Contents GENERAL INFORMATION... 3 PRACTITIONER SERVICES PROVIDED IN ARTICLE 28 FACILITIES... 5 MMIS MODIFIERS... 5 MEDICINE

More information

Test Content Outline Effective Date: December 23, 2015

Test Content Outline Effective Date: December 23, 2015 Board Certification Examination There are 200 questions on this examination. Of these, 175 are scored questions and 25 are pretest questions that are not scored. Pretest questions are used to determine

More information

Cultural Competence in Healthcare

Cultural Competence in Healthcare Cultural Competence in Healthcare WWW.RN.ORG Reviewed May, 2017, Expires May, 2019 Provider Information and Specifics available on our Website Unauthorized Distribution Prohibited 2017 RN.ORG, S.A., RN.ORG,

More information

Sonoma State University Department of Nursing

Sonoma State University Department of Nursing Sonoma State University Department of Nursing MASTER OF SCIENCE & POST MASTER S CERTIFICATE FAMILY NURSE PRACTITIONER PROGRAM FNP Clinical Preceptorship Packet FAMILY NURSE PRACTITIONER (FNP) PRECEPTORSHIP

More information

Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician

Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR 97031 541-387-6125 fax 541-387-6315 Physician Welcome to the Columbia Gorge Heart Clinic. We welcome you as a patient and

More information

Student Objectives for the Integrated Curriculum Evaluation Exercise

Student Objectives for the Integrated Curriculum Evaluation Exercise Student Objectives for the Integrated Curriculum Evaluation Exercise (1) Perform organized problem focused medical interviews and physical examinations, and conduct appropriate counseling for patients

More information

PRUPARENT/PRUHOSPITAL INCOME ROOM & BOARD/SURGICAL BENEFIT MEDICAL REPORT FORM (To be completed by Medical Attendant)

PRUPARENT/PRUHOSPITAL INCOME ROOM & BOARD/SURGICAL BENEFIT MEDICAL REPORT FORM (To be completed by Medical Attendant) Reg. 199002477Z PRUPARENT/PRUHOSPITAL INCOME ROOM & BOARD/SURGICAL BENEFIT MEDICAL REPORT FORM (To be completed by Medical Attendant) Policy Number Part 1 Medical Information 1. Name of Patient 2. NRIC

More information

Evaluation and Management Auditing Back to the Basics. Objectives. Audit Start with the benchmarks CMS MEDPAR by specialty 4/22/2013

Evaluation and Management Auditing Back to the Basics. Objectives. Audit Start with the benchmarks CMS MEDPAR by specialty 4/22/2013 Evaluation and Management Auditing Back to the Basics E&M Audit Sonda Kunzi, CPC, CPMA, CPPM, CPC-I Associate Director, Cohen Healthcare Consulting Ltd. Objectives Discuss good basic audit techniques Review

More information

Health Care Response to Domestic Violence

Health Care Response to Domestic Violence Health Care Response to Domestic Violence Domestic Violence Nurses, Physicians and clinicians who care for abuse victims must Recognize domestic violence as a major health care problem Understand the power

More information

Video Process Recording and Analysis Guidelines: 50 points

Video Process Recording and Analysis Guidelines: 50 points Video Process Recording and Analysis Guidelines: 50 points Video Process Recording is a recording and written account of an interaction between a pair of students who enact a nurse/patient interview and

More information

Behavioral Health Services

Behavioral Health Services PeaceHealth Medical Group 1200 Hilyard St., Suite 460 1200 Hilyard St., Suite 420 4010 Aerial Way 3333 RiverBend Eugene, OR 97401 Eugene, OR 97401 Eugene, OR 97402 Springfield, OR 97477 (541) 685-1794

More information

Filling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with?

Filling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with? Filling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with? 1. 2. 3. IMPORTANT PLEASE BRING A COMPUTER DISK WITH ANY BRAIN

More information

6/14/2017. Evaluation and Management Coding. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA

6/14/2017. Evaluation and Management Coding. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA Evaluation and Management Coding Jeffrey D. Lehrman, DPM, FASPS, MAPWCA APMA Coding Committee APMA MACRA Task Force Expert Panelist, Codingline Fellow, American Academy of Podiatric Practice Management

More information

HISTORY AND PHYSICAL EXAM

HISTORY AND PHYSICAL EXAM TO: PHYSICIAN COMPLETING THIS MEDICAL INFORMATION You are being presented papers for completion in reference to application for admission to The Virginia Home by a patient of yours. As you probably know,

More information

Course ID Course Name Course Outcome Introduction to Interviewing and Counseling

Course ID Course Name Course Outcome Introduction to Interviewing and Counseling Course ID Course Name Course Outcome MENT 40 Introduction to Interviewing and Counseling Demonstrate awareness of personal skills in the helping professions. (mo) Determine where and in which circumstances

More information

NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES

NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES Table of Contents GENERAL INFORMATION ------------------------------------------------------------------------------------------ 2 STATE DEPARTMENT

More information

Fulcrum Orthopaedics Patient Registration Packet

Fulcrum Orthopaedics Patient Registration Packet Fulcrum Orthopaedics Patient Registration Packet 2 Patient Information Form 8 Consent for Use and Disclosure of Information 9 Authorization for Use and Disclosure of Protected Health Information 10 Notice

More information

Descriptions: Provider Type and Specialty

Descriptions: Provider Type and Specialty Descriptions: Provider Type and Specialty PROVIDER TYPE/SPECIALTY ADULT PRIMARY CARE Provides care for adults by treating common health problems, performing check-ups and providing prevention services.

More information

Communication Skills. Assignments textbook reading, pp workbook exercises, pp

Communication Skills. Assignments textbook reading, pp workbook exercises, pp 15 3 Communication Skills 1. Define important words in this chapter 2. Explain types of communication 3. Explain barriers to communication 4. List ways that cultures impact communication 5. Identify the

More information

Overview. Chapter 2. The Well-Being of the EMT-Basic. Emotional Aspects of Emergency Care 9/11/2012. Death and dying

Overview. Chapter 2. The Well-Being of the EMT-Basic. Emotional Aspects of Emergency Care 9/11/2012. Death and dying Chapter 2 The Well-Being of the EMT-Basic Slide 1 Overview Emotional Aspects of Emergency Care Stressful Situations Stress Management Critical Incident Stress Debriefing Comprehensive Critical Incident

More information

Education & Training Plan

Education & Training Plan Ed4 (Created 9-10-15) AUBURN O FFICE OF P ROFESSIONAL AND CONTINUING EDUCATION Office of Professional & Continuing Education 301 OD Smith Hall Auburn, AL 36849 http://www.auburn.edu/mycaa Contact: Shavon

More information

CNUR 816 HEALTH ASSESSMENT FALL 2014 SAMPLE COURSE OUTLINE *

CNUR 816 HEALTH ASSESSMENT FALL 2014 SAMPLE COURSE OUTLINE * CNUR 816 HEALTH ASSESSMENT FALL 2014 SAMPLE COURSE OUTLINE * *Please note this is a sample course outline, you will be provided with a confirmed course outline with scheduling details on your first day

More information

Julie Gussenhoven, OD 3416 Bechelli Lane Redding, CA 96002

Julie Gussenhoven, OD 3416 Bechelli Lane Redding, CA 96002 Julie Gussenhoven, OD OCULAR AND MEDICAL HISTORY QUESTIONNAIRE Name: M F Date: Date of Birth: Home Phone: Social Security #: Cell Phone: Address: Work Phone: City: Zip: Email: Please complete all personal

More information

Pediatric In Training History And Physical Examination Assessment

Pediatric In Training History And Physical Examination Assessment Pediatric In Training History And Physical Examination Assessment PREAMBLE The requirement for Pediatric residency training programs to perform and document by observation an assessment of each resident's

More information

Bossier Parish Community College Master Syllabus

Bossier Parish Community College Master Syllabus Course Prefix and Number: STEC 101 Credit Hours: 1 Bossier Parish Community College Master Syllabus Course Title: Orientation to Surgical Technology Course Prerequisites: BLGY 110, 120/120L or 224/224L,

More information

CNUR 820 GERONTOLOGICAL AND GERIATRIC NURSING FALL 2014 SAMPLE COURSE OUTLINE *

CNUR 820 GERONTOLOGICAL AND GERIATRIC NURSING FALL 2014 SAMPLE COURSE OUTLINE * CNUR 820 GERONTOLOGICAL AND GERIATRIC NURSING FALL 2014 SAMPLE COURSE OUTLINE * *Please note this is a sample course outline, you will be provided with a confirmed course outline with scheduling details

More information

Overview SKASS2. Control the movement of spectators and deal with crowd issues at an event

Overview SKASS2. Control the movement of spectators and deal with crowd issues at an event issues at an Overview This standard is about keeping a careful watch over spectators including their entry to and exit from the venue. It also covers dealing with crowd issues such as unexpected movements,

More information

Aberdeen School District Food Service

Aberdeen School District Food Service Aberdeen School District Food Service Susan Nash, Director of Food Service 1224 S 3rd St Aberdeen, SD 57401 (605) 725.7131 Fax (605) 725.7198 TO: Parent/Guardian of Student(s) Requesting Special Menus

More information

Death and Dying. Shelley Westwood, RN, BSN Bullitt Central High School

Death and Dying. Shelley Westwood, RN, BSN Bullitt Central High School Death and Dying Shelley Westwood, RN, BSN Bullitt Central High School Objectives The student will: Explain the stages of death and dying including the philosophy of hospice care Contents Stages of Death

More information

Program Description PATIENT CARE ACADEMY

Program Description PATIENT CARE ACADEMY Program Description PATIENT CARE ACADEMY M-TEC at The Groves Campus 7107 Elm Valley Drive Kalamazoo, MI 49009 Phone: 269.353.1282 Fax: 269.353.1580 careeracademies@kvcc.edu www.kvcc.edu/training PATIENT

More information

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH CHAPTER 709, SUBCHAPTER F. STANDARDS FOR INPATIENT NONHOSPITAL ACTIVITIES SHORT-TERM DETOXIFICATION

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH CHAPTER 709, SUBCHAPTER F. STANDARDS FOR INPATIENT NONHOSPITAL ACTIVITIES SHORT-TERM DETOXIFICATION COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH CHAPTER 709, SUBCHAPTER F. STANDARDS FOR INPATIENT NONHOSPITAL ACTIVITIES SHORT-TERM DETOXIFICATION 709.61. Exceptions to the general standards for free-standing

More information

Retina Center of Oklahoma Demographic Information Sam S. Dahr,MD

Retina Center of Oklahoma Demographic Information Sam S. Dahr,MD Retina Center of Oklahoma Demographic Information Sam S. Dahr,MD PATIENT LAST NAME: FIRST NAME: MI: MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE: WORK PHONE: CELL PHONE: MARITAL STATUS: DATE OF BIRTH:

More information

E/M Fast Finder. CPT only 2012 American Medical Association. 1 All Rights Reserved.

E/M Fast Finder. CPT only 2012 American Medical Association. 1 All Rights Reserved. E/M Fast Finder The E/M Fast Finder is a carry-along reference to assist in assigning the Evaluation and Management (E/M) codes that are part of the 99000 series of Current Procedural Terminology (CPT

More information

Capital Area School of Practical Nursing Fundamentals of Nursing with Medical Terminology Course Syllabus

Capital Area School of Practical Nursing Fundamentals of Nursing with Medical Terminology Course Syllabus Course Information: Time: 12:30 4:00 p.m. Theory Contact Hours: 143.5 Instructor Information: Karen Durr RN BSN Office: 217-585-1215 ext. 207 Email: sdurr@caspn.edu Capital Area School of Practical Nursing

More information

Pediatric Psychology

Pediatric Psychology Pediatric Psychology Welcome to Pediatric Psychology at CHOC Children's. Please read this information carefully and write down any questions that you might have, so that we can discuss them. PSYCHOLOGICAL

More information

Eastern Palliative Care. Model of care

Eastern Palliative Care. Model of care Eastern Palliative Care Model of care 2009 Model of Care At EPC we actively engage with people and their families to develop a therapeutic relationship. We journey with them, recognising the essence of

More information

Appendix A: The Paramedic Foundation Community Paramedic Survey

Appendix A: The Paramedic Foundation Community Paramedic Survey Appendix A: The Paramedic Foundation Community Paramedic Survey 2015 October 2015 The Paramedic Foundation Community Paramedic Survey Minnesota Department of Health Office of Rural Health and Primary Care

More information

SKILLS CHECKLIST FOR RECERTIFICATION

SKILLS CHECKLIST FOR RECERTIFICATION NAME BLS-2017-Altered Mental States EMERGENCY MEDICAL SERVICES (11/10 MH) Objective: Given a partner, appropriate equipment and an altered mental status, demonstrate appropriate assessment and treatment

More information

Unit 301 Understand how to provide support when working in end of life care Supporting information

Unit 301 Understand how to provide support when working in end of life care Supporting information Unit 301 Understand how to provide support when working in end of life care Supporting information Guidance This unit must be assessed in accordance with Skills for Care and Development s QCF Assessment

More information

Charting for Midwives. Getting Credit For the Work You Do

Charting for Midwives. Getting Credit For the Work You Do Charting for Midwives Getting Credit For the Work You Do Moving Beyond S.O.A.P. The U.S. health care system is moving past fee-for-service billing. In the future, the providers will be reimbursed based

More information

Fulcrum Orthopaedics Patient Registration Packet

Fulcrum Orthopaedics Patient Registration Packet Fulcrum Orthopaedics Patient Registration Packet 2 Patient Information Form 9 Consent for Use and Disclosure of Information 10 Authorization for Use and Disclosure of Protected Health Information 11 Notice

More information

Office of Compliance. Complete & Accurate Documentation Core Curriculum for GWU Residents

Office of Compliance. Complete & Accurate Documentation Core Curriculum for GWU Residents Office of Compliance Complete & Accurate Documentation Core Curriculum for GWU Residents December 3, 2014 Medical Record The medical record tells the story of the patient from start to finish. If the story

More information

NEW PATIENT INFORMATION: ADULT

NEW PATIENT INFORMATION: ADULT NEW PATIENT INFORMATION: ADULT Patient Last Name: Patient First Name: Patient Middle Name: DOB: Sex: M F SSN: Address: City: Zip: Home Phone: Cell Phone: Email: EMERGENCY CONTACT INFORMATION Last Name:

More information

SECTION 3. Behavioral Health Core Program Standards. Z. Health Home

SECTION 3. Behavioral Health Core Program Standards. Z. Health Home SECTION 3 Behavioral Health Core Program Standards Z. Health Home Description Health home is a healthcare delivery approach that focuses on the whole person and provides integrated healthcare coordination

More information

Person to Contact in Case of Emergency. THE COUNSELING PLACE YOUTH INTAKE FORM Yearly Family Income:

Person to Contact in Case of Emergency. THE COUNSELING PLACE YOUTH INTAKE FORM Yearly Family Income: Person to Contact in Case of Emergency Name Relationship Best Contact Number Alt. Number Office Use Only Intake Date Reason for referral Counselor Who Can Pick Up Client (if Minor) THE COUNSELING PLACE

More information

Care on a hospital ward

Care on a hospital ward Care on a hospital ward People with dementia may be admitted to general hospital wards either as part of a planned procedure such as a cataract operation or following an accident such as a fall. Carers

More information

Educational Goals & Objectives

Educational Goals & Objectives Educational Goals & Objectives The Women s Health rotation will provide the resident with an opportunity to become skilled in the prevention, evaluation and management of conditions unique to women, from

More information

We ve got Your Back Competency & Compassion in Spinal Injury Nursing

We ve got Your Back Competency & Compassion in Spinal Injury Nursing We ve got Your Back Competency & Compassion in Spinal Injury Nursing Presentation by Jacqui Byrne SDF Ortho/Spinal Surgery Cancer & Surgery Directorate October 2016 NSIU - Background National Spinal Injuries

More information

Patient rights and responsibilities

Patient rights and responsibilities Patient rights and responsibilities (Also: Billing FAQs) Legacy Health Patient Information: Rights/Responsibilities, It s OK to Ask, Billing FAQs 1 Patient rights and responsibilities Your hospital experience

More information

Evaluation & Management

Evaluation & Management Evaluation & Management Shannon O. DeConda CPC, CPC-I, CPMA, CEMC, CEMA, CRTT President, NAMAS Partner, DoctorsManagement Evaluation and Management Components We will now look at the each of the components

More information