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3.01 record and report patient data
- 1. RReeccoorrdd aanndd RReeppoorrtt PPaattiieenntt DDaattaa 3.01 Understand Diagnostic and Therapeutic Services 1
- 2. RReeccoorrdd PPaattiieenntt DDaattaa • Patient data must be recorded accurately. • Document procedures as you do them. • Use the proper format and appropriate forms. • Record results in BLACK ink. 3.01 Understand Diagnostic and Therapeutic Services 2
- 3. CCoolllleecctt PPaattiieenntt DDaattaa PPaattiieenntt AAsssseessssmmeenntt AAsssseessssmmeenntt Objective 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 3
- 4. RReeccoorrdd PPaattiieenntt DDaattaa SSOOAAPP NNootteess • SSubjective observations: what the patient states (symptoms) • OObjective observations: what is seen or measured (signs) • AAssessment: normal versus abnormal • PPlan: what will be done 3.01 Understand Diagnostic and Therapeutic Services 4
- 5. RReeccoorrdd PPaattiieenntt DDaattaa Subjective observations: what the patient states (symptoms) • “My tooth hurts.” • “My jaw aches.” • “I bit my tongue.” 3.01 Understand Diagnostic and Therapeutic Services 5
- 6. RReeccoorrdd PPaattiieenntt DDaattaa Objective observations: what is seen or measured (signs) 3.01 Understand Diagnostic and Therapeutic Services color amount or size temperature blood pressure location 6
- 7. RReeccoorrdd PPaattiieenntt DDaattaa 3.01 Understand Diagnostic and Therapeutic Services • Assessment: normal versus abnormal 7
- 8. RReeccoorrdd PPaattiieenntt DDaattaa • Plan: what will be done? 3.01 Understand Diagnostic and Therapeutic Services 8
- 9. RReeccoorrdd PPaattiieenntt DDaattaa SSOOAAPP NNootteess • SSubjective observations: what the patient states (symptoms) • OObjective observations: what is seen or measured (signs) • AAssessment: normal versus abnormal • PPlan: what will be done 3.01 Understand Diagnostic and Therapeutic Services 9
- 10. RReeccoorrdd PPaattiieenntt DDaattaa SSuubbjjeeccttiivvee oorr oobbjjeeccttiivvee?? 3.01 Understand Diagnostic and Therapeutic Services 10
- 11. RReeccoorrdd PPaattiieenntt DDaattaa SSuubbjjeeccttiivvee oorr oobbjjeeccttiivvee?? 3.01 Understand Diagnostic and Therapeutic Services 11
- 12. RReeccoorrdd PPaattiieenntt DDaattaa SSuubbjjeeccttiivvee oorr oobbjjeeccttiivvee?? 3.01 Understand Diagnostic and Therapeutic Services 12
- 13. RReeccoorrdd PPaattiieenntt DDaattaa SSuubbjjeeccttiivvee oorr oobbjjeeccttiivvee?? 3.01 Understand Diagnostic and Therapeutic Services 13
- 14. RReeccoorrdd PPaattiieenntt DDaattaa SSuubbjjeeccttiivvee oorr oobbjjeeccttiivvee?? A B 3.01 Understand Diagnostic and Therapeutic Services 14
- 15. HHooww wwoouulldd yyoouu rreeccoorrdd tthhee ffoolllloowwiinngg ssttaatteemmeenntt?? • The patient is having a seizure. 3.01 Understand Diagnostic and Therapeutic Services 15
- 16. HHooww wwoouulldd yyoouu rreeccoorrdd tthhee ffoolllloowwiinngg ssttaatteemmeenntt?? • The patient is nervous. 3.01 Understand Diagnostic and Therapeutic Services 16
- 17. HHooww wwoouulldd yyoouu rreeccoorrdd tthhee ffoolllloowwiinngg ssttaatteemmeenntt?? • The patient has dermatitis. 3.01 Understand Diagnostic and Therapeutic Services 17
- 18. HHooww wwoouulldd yyoouu rreeccoorrdd tthhee ffoolllloowwiinngg ssttaatteemmeenntt?? • The patient is cyanotic. 3.01 Understand Diagnostic and Therapeutic Services 18
- 19. RReeppoorrtt PPaattiieenntt DDaattaa 3.01 Understand Diagnostic and Therapeutic Services 19
- 20. RReeppoorrtt PPaattiieenntt DDaattaa 3.01 Understand Diagnostic and Therapeutic Services Oral 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 20
- 21. RReeppoorrtt PPaattiieenntt DDaattaa WWrriitttteenn rreeppoorrttss: •Test results or observations are relayed on the patient’s medical record •The medical record is a legal document. •Information must be accurate 3.01 Understand Diagnostic and Therapeutic Services 21
- 22. SSuummmmaarryy:: CCoolllleecctt,, RReeccoorrdd,, RReeppoorrtt PPaattiieenntt DDaattaa • 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 3.01 Understand Diagnostic and Therapeutic Services 22
Editor's Notes
- NEVER use any other color ink or pencil when documenting. Only used approved abbreviations when documenting. Your documentation needs to be neat and legible. What you document becomes part of the legal medical record. It can and will be used in court if needed.
- Headache/pain= subjective because there is no way to measure
- Pain in head or pressure in head= subjective because there is no way to measure
- Facial dropping= objective because it can be observed ( the right side of patient’s mouth is lower than the left) (REMEMBER it is the patient’s right side not yours when you are documenting)
- Blood pressure= objective because you are able to measure it
- Rash or skin lesions= objective because you can see it, feel it, smell it
- Patient on floor with “jerky” tonic clonic movements of entire body.
- Patient is room getting dressed. Observed hands shaking and look of concern on face.
- Patient’s axillae (arm pits), arms, chest and neck has reddened raised areas.
- Patient’s right is blue in color.
- Written in BLACK ink and legible. If you make an error, NEVER use eraser or white out/correction tape. You should put a single line through the error and place your initials with the date on it. Also ALWAYS document(write) what you did AFTER you did it. NEVER write it first because you never know what might happen and it may not get done. That would result in a falsification of documentation. You could be legally prosecuted if you did this!!!!