Recording and Reporting Patient Data

Report
Record and Report
Patient Data
3.01 Understand Diagnostic and
Therapeutic Services
1
Record Patient Data
• 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
Collect Patient Data
Patient Assessment
Assessment
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
Record Patient Data
SOAP Notes
• Subjective observations: what
the patient states (symptoms)
• Objective observations: what
is seen or measured (signs)
• Assessment: normal versus
abnormal
• Plan: what will be done
3.01 Understand Diagnostic and
Therapeutic Services
4
Record Patient Data
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
Record Patient Data
Objective observations:
what is seen or measured (signs)
location
3.01 Understand Diagnostic and
Therapeutic Services
6
Record Patient Data
• Assessment:
normal versus abnormal
3.01 Understand Diagnostic and
Therapeutic Services
7
Record Patient Data
• Plan: what will be done?
3.01 Understand Diagnostic and
Therapeutic Services
8
Record Patient Data
SOAP Notes
• Subjective observations: what
the patient states (symptoms)
• Objective observations: what
is seen or measured (signs)
• Assessment: normal versus
abnormal
• Plan: what will be done
3.01 Understand Diagnostic and
Therapeutic Services
9
Record Patient Data
Subjective or objective?
3.01 Understand Diagnostic and
Therapeutic Services
10
Record Patient Data
Subjective or objective?
3.01 Understand Diagnostic and
Therapeutic Services
11
Record Patient Data
Subjective or objective?
3.01 Understand Diagnostic and
Therapeutic Services
12
Record Patient Data
Subjective or objective?
3.01 Understand Diagnostic and
Therapeutic Services
13
Record Patient Data
Subjective or objective?
A
B
3.01 Understand Diagnostic and
Therapeutic Services
14
How would you record the
following statement?
• The patient is having a seizure.
3.01 Understand Diagnostic and
Therapeutic Services
15
How would you record the
following statement?
• The patient is nervous.
3.01 Understand Diagnostic and
Therapeutic Services
16
How would you record the
following statement?
• The patient has dermatitis.
3.01 Understand Diagnostic and
Therapeutic Services
17
How would you record the
following statement?
• The patient is cyanotic.
3.01 Understand Diagnostic and
Therapeutic Services
18
Report Patient Data
3.01 Understand Diagnostic and
Therapeutic Services
19
Report Patient Data
Oral reports:
– Report observations, patient results or requests to
supervisor/staff prior to leaving the area.
– Report abnormal results to supervisor
Team reports
immediately.
Individual reports
3.01 Understand Diagnostic and
Therapeutic Services
20
Report Patient Data
Written reports:
• 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
Summary:
Collect, Record, Report
Patient Data
• 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

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