Patient Assessment. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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1 Patient Assessment
2 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 physical, emotional, social, economic and spiritual needs of the person
3 Objectives Apply critical thinking in performing patient assessments. Describe the components of the patients medical history. Define empathy. Detect the patients use of defense mechanisms and restraint barriers to therapeutic communication.
4 Medical History: Collecting the Information In addition to being useful for diagnosing and treating the patient, the self-history allows the patient more participation in the process. The form may be mailed to the patient s home before the appointment or may be completed in the office during the first visit. If you are responsible for taking a portion of the medical history, conduct the interview in a private area free from outside interference and beyond the hearing range of other patients.
5 Collecting the Medical Information The interview room should be physically comfortable and conducive to confidential communications. Do not express surprise or displeasure at any of the patient s statements. Record the information in an organized manner, exactly as given by the patient, without opinion or interpretation. Include CC, vital signs, weight, height, pain scale.
6 The Medical History The medical history consists of: Patient s database Past medical history (PMH) Family history (FH) Social history (SH) Review of systems (ROS)
7 Understanding and Communicating with Patients Positive reactions and interactions with patients are essential for a therapeutic relationship. The interpersonal nature of the patient medical assistant relationship carries with it a certain amount of responsibility to detach one s self-interest and focus on the needs of the patients.
8 Empathy is the key to creating a caring, therapeutic environment. Requires those interested in healthcare services to examine their own values, beliefs, and actions. Sensitivity to Diversity
9 Therapeutic Techniques: Active Listening Listening must be an active process in a therapeutic relationship. Restatement Reflection Clarification
10 Therapeutic Techniques: Nonverbal Communication Approximately 90% of patient interactions occur through nonverbal language. Successful patient interaction has congruent verbal and nonverbal messages.
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12 Preparing the Appropriate Environment Ensure privacy. Refuse interruptions. Prepare comfortable surroundings. Take judicious (careful) notes.
13 Open-Ended Questions Designed to give the patient the opportunity to provide additional information. What brings you to the doctor? How have you been getting along? You mentioned having dizzy spells. Tell me more about that.
14 Closed-Ended Questions Asked for specific information that can be answered with only a few words. Do you have a headache? What is your birth date? Have you ever broken a bone?
15 Interviewing the Patient Contract between the medical assistant and patient Three parts initiation or introduction the body the closing
16 Interview Barriers Providing unwarranted assurance Giving advice Using medical terminology Asking leading questions Talking too much Using defense mechanisms
17 Communication across the Lifespan Therapeutic communication techniques vary with the patient. Be aware of how to interact most effectively with young children, adolescents, adults, and their families. Use an age-specific approach.
18 Health History of a Child The environment should be safe and attractive. Do not keep children and their caregivers waiting any longer than necessary. Do not offer a choice unless the child can truly make one. Giving a child a choice of stickers after an injection is appropriate, but asking her if she would like her shot now is not.
19 Child s Examination Praising the child helps decrease anxiety. When possible, direct questions to the child so he or she feels part of the process. Involve the child by permitting him or her to manipulate the equipment. Use your imagination to make a game of the assessment or the procedure.
20 Child s Examination A typical defense mechanism seen in sick or anxious children is regression. The child may refuse to leave her mother s lap or may want to hold a favorite toy during the procedure. Look for signs of anxiety such as thumb-sucking or rocking.
21 Treating Adolescents They should be involved in treatment. Provide opportunities for a teenager to exert his or her independence. Privacy is very important; keep body exposure to a minimum. Want to know what is going on and what to expect; keep adolescent informed, and answer all questions. Stress healthy life habits and decisions.
22 Adult Patients Patient education is extremely important. Use lay language, and involve the patient in treatment. Stress-related health problems are frequently seen. Emphasize preventive healthcare measures.
23 Recognizing and Responding to Verbal and Nonverbal Communications The medical assistant not only must implement therapeutic communication skills but also must observe the patient to determine the patient s message and level of understanding.
24 Patient Body System Assessment Appearance Head and neck Eyes Nose Ears Mouth and throat Respiratory Cardiovascular Gastrointestinal Urinary Genitalia (male/female) Lymph glands Neurologic Endocrine Skin Arms, legs, and feet
25 Signs objective findings Signs and Symptoms Something that can be measured, inspected, palpated, auscultated, or manipulated Symptoms subjective report from patient Patient complaints regarding how he or she feels Measure pain on a scale of 1 to 10 Cardinal symptoms: those most helpful in diagnosis Functional vs. physical (organic)
26 Documentation Accurate and complete documentation is a necessary skill. Describe the patient s chief complaint (C/C) and all pertinent signs and symptoms, and demonstrate the correct use of medical terminology and appropriate abbreviations. Correct any error in the medical record according to legally approved methods. Use SOAP format chart.
27 SOAP Notes S subjective data: C/C in patient words O objective data: anything that is observed or measurable A assessment: physician s tentative diagnosis P plan of care: physician documents how health problem will be managed
28 Patient Education The perfect time to initiate patient education is during the initial patient interview. Make sure you stay in the scope of your practice. Educate the patient. DO NOT diagnose!
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