1. Communication techniques used to obtain a patient’s health history (found in Seidel’s guide to physical examination, chapte... [Show More] r 1, pages 1-7)
a. Ask the patient how the prefer to be addressed
b. Ask open-ended questions. Ensure to let the patient have time to discuss their concerns.
c. Be courteous- Knock before entering, ensure confidentiality, meet and acknowledge others that may be in the room and level of participation, respect modesty, allow patient to dress after examination before follow-up discussion
d. Ensure comfort- ensure physical comfort, have minimal furniture, maintain privacy, comfortable room temperature, good lighting, and do not overtire the patient
e. Establish a connection- Maintain good eye contact (if cultural preferences allow), avoid professional jargon, actively listen, establish the patients history and conduct the physical exam before viewing previous studies and tests to avoid a predetermined path, be flexible, watch nonverbal cues, define concerns completely (where, severity, length, context, soothers/aggravators)
f. Establish confidentiality- Have patient summarize the discussion, allow more discussion if the patient has other concerns by asking “anything else you would like to bring up,” follow-up if there are questions you are unable to answer right away, if you make a mistake own up to it and make every effort to repair it
g. Ensure appropriate dress and grooming paying attention to clean fingernails, modest clothing, and neat hair.
h. Seek certainty if patients responses to questions are unclear
i. Be direct and firm when discussing sensitive issues and document after the discussion is over
Medical record should be complete and legible
Each patient encounter should include
Reason for encounter (Chief Complaint)
Relevant history, PE findings, and test results
Assessment, clinical impressions, or diagnosis
Plan of care
Date and legible identity of the observer
Why test was ordered
3. SOAP notes are a quick and efficient way to compile information and make decisions based on the information provided by the patient.
The information for SOAP notes can be found in the Sullivan Text
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
S-Chief Compliant (CC), history of present illness (HPI), Pertinent past medical history (PMH), Pertinent family history (FH), Pertinent psychosocial history (SH), any specialized history related to the chief complaint, and Pertinent review of systems (ROS) (Sullivan, pp.91-92).
O- Objective: includes the vital signs, a general assessment of the patient, physical examination findings, results from laboratory or diagnostic tests (Sullivan, p. 93)
A- Assessment: is an analysis and interpretation of the subjective and objective data to provide a diagnosis or a list of differential diagnoses (Sullivan, pp. 96-97).
P- Plan: this area includes diagnostic studies that will be obtained, referrals, therapeutic interventions, educational material, disposition of the patient, next visit (Sullivan, p. 99)
4. Subjective Data vs Objective Data (#4)
Information collection is a vital piece of any assessment process, regardless of whether it is for risk management, a health diagnosing, or an execution assessment. The emotional and target techniques for information accumulation are two conspicuous ones used to decide the kind of information gathered and the suspicions. While the previous is identified with verbal articulation of thought and the statements to take after, the last is identified with unquestionable and strong actuality.
o Subjective data or abstract information is information that is gathered or acquired through personal interactions, i.e., talking, sharing, clarifying, and so forth.
o It is gathered to make an assumption about what the reality may be, what occasion may have happened, what estimations must be done, and so on.
o Subjective information can likewise be gathered by methods for judgment, doubt, or rumors
o This information fluctuates from one person to another, with each circumstance, consistently.
o It can't be announced as reality, as it advances from such a large number of changed sources with various information sources.
o Abstract dialect as a rule starts with, 'I think', 'I require', 'I feel', and so on
o By definition, objective data is information that is gathered or acquired by means of established or obvious realities and sources.
o It is gathered to affirm your doubts and suppositions - or only to accumulate trustworthy data. It is something that can be felt, contacted, smelled, seen, heard, and tasted.
o Objective information will be the same from numerous sources and can be checked and portrayed precisely and affirmed.
o This information does not fluctuate from one person to another or with each circumstance.
o It tends to be proclaimed as evident information since it stays same and reliable regardless of whether numerous sources are included.
o Objective dialect more often than not starts with 'I said', 'I watched', 'I gauged', and so forth. [Show Less]