Importance of patient observation, method of observation, the importance of verbal communication, the importance of documentation

1. Module - 5
Sub code: MLT504
Sub Name: Medical Lab Technician – I (T)
Semester: V
Department: Department of MLT, SMAS
Faculty: A. Vamsi Kumar
Designation : Assistant professor
MINI CHATURVEDI
5 Importance of Observing patients
during sample and report collection
MOHAMMAD JUNED
5 method of Observing and reporting
while assisting the pathologists and
other members of the team
MOHD SAIF ALI
5 importance of verbally informing the
person in authority
NIKHIL SHARMA 5 Importance of Documentation

2. Importance of Observing patients
during sample and report collection
By
Mini Chaturvedi

3. Importance of Observing patients during sample and
report collection
• Observation is an important component of the patient
encounter that begins at the first point of contact with the
patient. Observation relates to information gained by using
one's senses during the examination and encompasses
physical findings as well as behavioral, situational, and
ancillary observations. A specific set of observations makes up
the general survey, which should be a part of every patient
encounter. Additional observations occur during each organ-
specific part of the physical examination, with inspection
accounting for the bulk of the skin examination. In addition to
direct observations of the patient, astute clinicians attend to
information in the patient's surroundings and social
relationships, as well as the feelings that patients may evoke
in them, as part of good patient care.

4. • Preparing the Patient
• Patient Instructions
• It is important to gain the patient's understanding and cooperation in
obtaining an acceptable specimen.
• Patient States
• Basal State. In general, specimens for determining the concentration of
body constituents should be collected when the patient is in a basal state
(ie, in the early morning after awakening and about 12 to 14 hours after
the last ingestion of food). Reference intervals are most frequently based
on specimens from this collection period.
• The composition of blood is altered after meals by nutrients being
absorbed into the bloodstream. Consequently, postprandial blood (blood
drawn after a meal) is not suitable for some chemistry tests. An overnight
fast is preferable (from 6 PM of the evening previous to collection) to
ensure that the patient is in the basal state. This minimizes the effects of
ingested substances on the test results. Before you collect the specimen,
ask the patient when he/she last ate or drank anything. If the patient has
eaten recently and the physician wants the test to be performed anyway,
you should indicate “nonfasting” on the test request form. In the clinical
information/comments section of the test request form, indicate the time
the patient ate. Fasting does include abstaining from coffee, tea, or sugar-
free products.

5. • Fasting or diet restrictions, such as low-fat diets,
should be explained in detail, particularly to aged
or overanxious patients or their caregivers.
Inform patients that fasting does not include
abstaining from water. Dehydration resulting
from water abstinence can alter test results.
• When specimens are not collected in the basal
state, the following additional effects should be
considered when interpreting test results.

6. • When specimens are not collected in the basal state,
the following additional effects should be considered
when interpreting test results.
1. Exercise. Moderate exercise can cause an increase in
blood glucose, lactic acid, serum proteins, and
creatine kinase (CK).
2. Emotional or Physical Stress. The clinical status of the
patient can cause variations in test results.
3. Time of Day of Collection. Diurnal variations and
variations in circadian rhythm can also affect test
results. For example, growth hormone peaks in the
morning before waking and decreases throughout the
day. Serum iron levels may change as much as 30% to
50%, depending on individual variation, from morning
until evening.
4. Note: For chemistry profiles, 12- to 14-hour fasting
specimens are recommended.

7. method of Observing and reporting while
assisting the pathologists and other members
of the team
By
Md. Juned

8. method of Observing and reporting while
assisting the pathologists and other members
of the team
• GENERAL OBSERVATIONS of a patient's appearance,
mobility, communication ability, and cognitive function
are an important part of your initial assessment. For
example, when documenting a patient's mobility, note
whether he can walk and move independently or
needs help, and whether he has weakness or paralysis.
Part of a good note might read:
• 2/12/06 0800—Unsteady gait, needs to use walker,
can't turn independently in bed because of weakness
in left leg. D. Orth, RN———
• Also look for and document the following
characteristics.

9. Appearance
1. Age: Does the patient appear to be his stated age, or does he look
older or younger?
2. Physical condition: Does he look healthy? Is his weight
appropriate for his height, or is he underweight or overweight?
Note any obvious limitations, such as an amputation.
3. Dress: Is he dressed appropriately for the season? Note whether
his clothing is clean and well kept, or soiled or torn.
4. Personal hygiene: Is he clean and well groomed, or unshaven and
unkempt, with dirty skin, hair or nails? Does he have a strong body
odor or unusual breath odor? Can you smell alcohol, urine, or
feces?
5. Skin: Look for obvious scars or rashes. Document any
abnormalities, such as an unusually pale or ruddy complexion,
cyanosis, or jaundice.

10. Communication
• Speech: Document whether he speaks clearly in English or another
language and note anything unusual—for example, provides only
one-word responses, doesn't respond when spoken to, speech is
slurred, hoarse, loud, soft, incoherent, hesitant, slow, fast, or
nonsensical. Indicate if he has trouble completing sentences
because of shortness of breath or pain.
• Hearing: Make sure he hears well enough to respond to questions.
If he's hearing impaired, note whether he hears better through one
ear or the other and whether he wears a hearing aid. If he's deaf,
assess whether he reads lips or uses sign language.
• Vision: Can he see well enough to read instructions in English or
another language? Document whether he needs glasses or contact
lenses to see or read, if he's blind, or if he can't read because he's
illiterate.

11. 1. Cognitive functions
1. Awareness: Is he oriented and aware of his
surroundings, or disoriented and unaware of time,
place, and person?
2. Mood: Does he respond to questions appropriately?
Is he talkative, or does he offer information only in
response to questions? Does he seem hesitant, avoid
eye contact, or look to a family member before
answering? Does he seem angry?
3. Thought processes: Note whether he can maintain a
conversation. Does he make relevant statements and
follow commands appropriately, or does his mind
wander?

12. Importance of verbally informing the
person in authority
By
Md. Saif Ali

13. Importance of verbally informing the
person in authority
• Verbal communication
• It almost goes without saying that we have to
give clear attention to what we say to
patients/clients. We need to ensure that what we
say is:
1. clear
2. accurate
3. honest
4. appropriate (to the person’s age,
language/culture and level of understanding).

14. • But just as important is how we say it. At all times
we must be:
1. Courteous and respectful: we need to make
sure we address patients/clients as they wish to
be addressed. Some may prefer you to call them
by their first names, while others might want a
more formal address. The key thing is to find out
what is right for each individual. And generally,
‘pet’ names – ‘love’, ‘dear’, ‘doll’ – shouldn’t be
used.
2. Encouraging: we should try to prompt
patients/clients to communicate with us by
saying encouraging things to them – ‘yes, do go
on’, ‘can you tell me a bit more about that?’

15. • Our tone of voice is also important.
• Patients/clients don’t like to feel they’re
holding you back from other duties, but they
can get that feeling if your tone of voice is
irritated or impatient. Things can get very busy
in health care, and you might feel as if you’re
being rushed off your feet, but try not to let
that seep into your voice – try to stay calm
and focused on the patient/client in front of
you. With practice, you’ll be able to perfect
this vital skill.

16. Importance of Documentation
By
Nikil Sharma

18. Importance of Documentation
• Good medical documentation promotes patients' and
physicians' best interests for different reasons.
• Recording all relevant information of a patient's care
helps practitioners monitor what's been done, and
minimizes the risk of errors creeping into the
treatment process.
• Careful attention to detail also reduces the likelihood
of patients returning for additional treatment. The
process also demands a high degree of self-evaluation
that's essential to promoting good clinical practices, as
well as a practitioner's professional development.