Modern view on history taking

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Modern view on history taking

  1. 2. Build a knowledge base from a series of questions
  2. 3. MODERN VIEW ON DIABETIC SHEET PR DR M A BADR
  3. 4. QUALITY OF CARE <ul><li>STRUCTURE </li></ul><ul><li>PROCESS : DOCUMENT , SHEET, GUIDE LINES </li></ul><ul><li>OUTCOME </li></ul>
  4. 5. QUALITY IMPROVEMENT & ASSURANCE <ul><li>CONSENSUS </li></ul><ul><li>GUIDELINES </li></ul><ul><li>EVIDENCE BASED MEDICINE </li></ul><ul><li>PERSONALIZED MEDICINE </li></ul>
  5. 6. What is Quality in Health Care? <ul><li>Quality health care means doing the right thing, at the right time, in the right way, for the right person—and having the best possible results. Although we would like to think that every health plan, doctor, hospital, and other provider gives high-quality care, this is not always so. Quality varies, for many reasons </li></ul>
  6. 7. Tools Needed for Prediction and Personalized Care Disease Burden Time Cost 1/reversibility Decision Support Tools: Baseline Risk Preclinical Progression Disease Initiation and Progression Assess Risk Refine Assessment Predict/Diagnose Monitor Progression Predict Events Inform Therapeutics Sources of New Biomarkers: Stable Genomics: Single Nucleotide Polymorphisms (SNPs) Haplotype Mapping Gene Sequencing Dynamic Genomics: Gene Expression Proteomics Metabolomics Molecular Imaging Therapeutic Decision Support Typical Current Intervention Earliest Clinical Detection Earliest Molecular Detection Initiating Events Baseline Risk
  7. 8. Prospective Health Care Risk Assessment and Decision Support Tools Personal Lifestyle Plan Disease Management Risk Modification Disease Burden Time Low Risk High Risk Early Chronic Cost 1/reversibility Personalized Health Plan Late Chronic Participating Population
  8. 9. Accreditation What is accreditation and what are the benefits? is a process in which an entity, separate and distinct from the health care organization, usually non-governmental, assess the health care organization to determine if it meets a set of standards requirements designed to improve quality of care. Accreditation is usually voluntary. Accreditation standards are usually regarded as optimal and achievable. Accreditation provides a visible commitment by an organization to improve the quality of patient care , to ensure a safe environment and to continually work to reduce risks to patients and staff. Accreditation has gained worldwide attention as an effective quality evaluation and management tool.
  9. 10. (International Organization for Standardization) Is the world's largest developer and publisher of I International Standards.
  10. 11. ISO is a network of the national standards institutes of 157 countries, one member per country, with a Central Secretariat in Geneva, Switzerland, that coordinates the system. ISO is a non-governmental organization that forms a bridge between the public and private sectors. On the one hand, many of its member institutes are part of the governmental structure of their countries, or are mandated by their government. On the other hand, other members have their roots uniquely in the private sector, having been set up by national partnerships of industry associations. Therefore, ISO enables a consensus to be reached on solutions that meet both the requirements of business and the broader needs of society. ISO forms a bridge between the public and private sectors.
  11. 12. What is JCI Accreditation? In response to growing interest in accreditation and quality improvement worldwide, the Joint Commission launched its international accreditation program in 1999. Joint Commission International accreditation standards are based on international consensus standards and set uniform, achievable expectations for structures, processes and outcomes for hospitals. The accreditation process is designed to accommodate specific legal, religious and cultural factors within a country. Joint Commission International (JCI) accreditation can help international health care organizations, public health agencies, health ministries and others to evaluate, improve and demonstrate the quality of patient care in their nations.
  12. 13. TYPE OF VISIT <ul><li>INITIAL , REFERRED </li></ul><ul><li>FOLLOW UP </li></ul><ul><li>QUARTERLY </li></ul><ul><li>ANNUAL </li></ul><ul><li>EMERGENCY </li></ul>
  13. 14. PERSONAL DATA <ul><li>DATE OF DIABETES DIAGNOSIS </li></ul><ul><li>PRESENCE OF SYMPTOMS BEFORE </li></ul><ul><li>BIRTH DATE </li></ul><ul><li>ADMISSION DATE, VISIT DATE </li></ul><ul><li>REGISTRATION NO </li></ul><ul><li>ALLERGY TO DRUGS, GENETIC DISEASES, SIKLING, G6PD …… </li></ul><ul><li>OCCUPATION,EFFORT ,SHIFT </li></ul>
  14. 15. PRESENTATION <ul><li>CLASSICAL SYMPTOMS OF DIABETES </li></ul><ul><li>COMPLICATIONS </li></ul><ul><li>DKA,HHS </li></ul><ul><li>INFECTION </li></ul><ul><li>VASCULAR,MI,STROKE,PVD </li></ul><ul><li>TYPE OF DIABETES DMT1,DMT2….. </li></ul>
  15. 16. METABOLIC SYNDROME & DIABETES <ul><li>HYPERTENSION </li></ul><ul><li>DYSLIPIDEMIA </li></ul><ul><li>OBESITY ABDOMINAL, RACIAL </li></ul><ul><li>HYPERGLYCEMIA </li></ul>
  16. 17. OTHER ASSOCIATIONS <ul><li>THYROID DISEASE </li></ul><ul><li>HEPATIC, ENDEMIC </li></ul><ul><li>TB, HIV </li></ul><ul><li>GALL BLADDER </li></ul>
  17. 18. INDIVIDUALIZED PLAN <ul><li>PHYSICAL ACTIVITY </li></ul><ul><li>NUTRITIONAL ADVICE </li></ul><ul><li>STOP SMOKING </li></ul><ul><li>REDUCE BODY WEIGHT </li></ul><ul><li>PERFORM SELF MONITORING </li></ul><ul><li>START TO USE RECORD BOOK </li></ul>
  18. 19. TARGET <ul><li>CONTROL OF SYMPTOMS </li></ul><ul><li>PREVENTION ACUTE METABOLIC COMPLICATIONS, HYPERGLYCEMIC CRISIS </li></ul><ul><li>DELAY CHRONIC COMPLICATIONS </li></ul><ul><li>CONTROL ASSOCIATED DISEASES </li></ul><ul><li>PROVIDE THE PATIENT WITH SATISFACTORY QUALITY OF LIFE </li></ul>
  19. 20. Drug History <ul><li>bid (Bis in die) - Twice daily (usually morning and night) </li></ul><ul><li>tds (ter die sumendus)/tid (ter in die) = Three times a day mainly 8 hourly </li></ul><ul><li>qds (quarter die sumendus)/qid (quarter in die) = four times daily mainly 6 hourly </li></ul><ul><li>Mane/(om – omni mane) = morning </li></ul><ul><li>Nocte/(on – omni nocte) = night </li></ul><ul><li>ac (ante cibum) = before food </li></ul><ul><li>pc (post cibum) = after food </li></ul><ul><li>po (per orum/os) = by mouth </li></ul><ul><li>stat – statim = immediately as initial dose </li></ul><ul><li>Rx (recipe) = treat with </li></ul><ul><li>PM,AM MILITARY TIME 19:45 </li></ul>
  20. 21. MEDICATIONS <ul><li>INSULIN </li></ul><ul><li>ORAL </li></ul><ul><li>ALTERNATIVE , COMPLEMENTARY </li></ul>
  21. 22. PATIENT COMPLIANCE <ul><li>NON COMPLIANCE </li></ul><ul><li>SELF MONITORING </li></ul><ul><li>DEGREE OF CONTROL </li></ul>
  22. 23. PRIORITY OF HEALTH EDUCATION <ul><li>TYPE OF PATIENT </li></ul><ul><li>INTELLECTUEL LEVEL </li></ul><ul><li>AGE, FAMILY SHARE </li></ul><ul><li>GESTATIONAL DIABETES </li></ul><ul><li>IN OR OUTPATIENT </li></ul>
  23. 24. EXAMINATION <ul><li>WAIST CIRCUMFERENCE, BMI,HT,WT </li></ul><ul><li>DETECTION OF POSTURAL HYPOTENSION </li></ul><ul><li>PERIPHERAL VASCULAR DISEASE </li></ul><ul><li>THYROID </li></ul><ul><li>ORAL HYGIENE </li></ul><ul><li>FEET EXAMINATION, PODIATRY </li></ul>
  24. 25. PERSON WITH DIABETES SHOULD KNOW <ul><li>NATURE OF DISEASE </li></ul><ul><li>SYMPTOMS OF HYPER AND HYPO </li></ul><ul><li>RISK OF COMPLICATIONS FEET </li></ul><ul><li>INDIDUAL TARGET TAILORED TREATMENT </li></ul><ul><li>INDIVIDUAL LIFE STYLE </li></ul><ul><li>IMPORTANCE OF EXERCISE </li></ul>
  25. 26. PERSON WITH DIABETES SHOULD KNOW <ul><ul><ul><li>SELF MONITORING,INSULIN ,INSULIN DOSE ADJUSTMENT </li></ul></ul></ul><ul><ul><ul><li>HOW TO COPE WITH EMERGENCY, HYPO, SICK DAYS </li></ul></ul></ul><ul><ul><ul><li>GESTATIONAL DIABETES </li></ul></ul></ul>

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