NURS 6512 Midterm Exam Review (Week 1-6)
Building A Complete Health History
⦁ Communication techniques used to obtain a patient’s health history
C... [Show More] ourtesy, Comfort, Connection, Confirmation
(i.e. knock on door before entering, learn their names, ensure confidentiality, ensure good lighting & temperature, don't overtire patient, maintain good eye contact, watch your language, avoid being judgemental, conduct a CPE, avoid leading or directing an answer, ask the patient to summarize discussion, allow time for questions, be honest if you do not know the answer)
⦁ Recording and documenting patient information
Documentation is most important:
•Chronologically documents the care of the patient & contributes to high-quality care
•Primary means of communication between healthcare team members which facilitates continuity care & communication among those involved with the patient's care
•Establishes your credibility as a healthcare provider (i.e., use professional language, include appropriate content)
•Legal implications:
• Provides evidence that appropriate care was given & how the patient responded to the care provided
• "If it was not documented, it was not done" - quote is important with considerable time-lapse that in a event where you may have to recall the events that occurred in court
•The Centers for Medicare and Medicaid Services (CMS) requires: (Sullivan, 2012, p. 2)
1. The medical record should be complete and legible
2. The documentation of each patient encounter should include the following:
•Reason for the encounter and relevant history, physical exam findings, and diagnostic test results
•Assessment, clinical impression, or diagnosis
•Plan for care
•Date and legible identity of the observer
3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred
4. Past and present diagnoses should be accessible to the treating and consulting providers
5. Appropriate health risk factors should be identified.
6.The patient's progress, response to and changes in treatment, and revision of diagnoses should be documented
7. The Current Procedural Terminology (CPT) and ICD-9 codes reported on the health insurance claim form or billing statement should be documentation. (Examples of how to document ICD code are on page 5 of Sullivan's).
• Maintain patient confidentiality (HIPPA)
• Patients and their respected parties have the right to view medical records with limitations (i.e., psychiatric patients cannot view provider's notes)
The Comprehensive History & Physical Exam
• Documents the patient's medical history, physical exam findings, diagnoses or medical problems, diagnostic studies to be performed, and initial plan of care implemented to address any problems identified.
•Do not copy another provider's H&P- always perform your own and if unable to then give credit to the provider responsible
•History includes: patient's personal identification
•Chief Complaint (CC)- why is the patient there? (Best stated in the patient's own words)
•History of the Present Illness or History of the CC: the chronological description of the development of the patient's present illness from the first sign or symptom of the presenting problems. Include identifying elements such as location, quality, severity, duration, timing, content, modifying factors, & associated sign and symptoms.
•Past Medical History: documents the patient's past and current health. Includes: Past medical history, past surgical history or other hospitalizations (provide dates if possible), medications, drug allergies, and health maintenance and immunizations.
•Family History: first-degree relatives includes parents, grandparents, and siblings with the age their age and status. If deceased, include the age at time of death and cause of death.
Psychosocial History: Identify factors that may influence the patient's overall health or behaviors that places the patient at risk for specific conditions. Includes patient's sexual orientation, marital status, children, occupation status, environmental risks, language preference (if interpreter required, it must be documented), religion/ cultural beliefs, tobacco/etoh/illicit drug use, diet, etc.
• Review of Systems (ROS): an inventory of specific body systems designed to document any symptoms the patient may be experiencing or has experienced. Includes positive and negative responses from patient
• Physical Examination: may confirm or refute a diagnosis suspected from the history and provide a more accurate problem list.
• Laboratory & Diagnostic Studies: laboratory tests, radiographs, or other imaging studies with specific values/results which allows readers to formulate their own conclusions, documents baseline values, and saves time for other readers to look values.
• Problem List, Assessment, and Differential Diagnosis: provider evaluates all the info to identify the patient's problems in a numbered list (includes date of onset and whether active/inactive) with the most severe problems listed first.
• Plan of Care: document any additional studies or workup needed, referrals or consults needed, pharmacological management, nonpharm.or other management patient education, and disposition (i.e., "return to clinic" or "admit to the hospital" [Show Less]
