• Benefits of therapy • The alternatives • Anticipated time frames • Cost • Risks • Consequence-personally liable if the patient not informed Informed Consent must be: • Comprehensible • Or provide translator • If patient not on legal age or mentally confused secure consent from: a. Legally qualified surrogate b. Parent c. Guardian d. Family member or e. Court-appointed advocate Principles of Documentation Elements of Documentation • Initial examination • Evaluation • Visit/encounter • Reexamination • Discharge • Discontinuation Other areas of consideration 1. Patient primary and treatment diagnosis 2. Physician’s orders 3. Patient barriers to treatment and their resolution 4. Patient’s consent to treatment 5. POC (goals, interventions, proposed frequency and duration, and discharge) 6. STG and LTG 7. Risk and benefit of treatment Problem Oriented Medical Record (POMR) on SOAP format 4Phases 1. Formation of a databases (current and past information about patient) 2. Development of specific, current problem list 3. Identification of specific treatment plan 4. Assessment of treatment plan effectiveness Rationale for Documentation • To assess patient improvement Quality of Life • For reimbursement • For referrals Principles of Patient Management Differential Diagnosis • When patient symptoms are associated with two or more illnesses • A systematic process to compare and contrast the symptoms to distinguish one illness or condition from the other. • Accurate diagnosis is the basis for better treatment decisions, plans, and outcomes and reduction of medical errors, and limits the possibility of inappropriate treatment. Components of DDx • 1. Observation and interviews • 2. Specific tests and measures Components: Patient Medical History 1. Primary complaint 2. Current illness 3. Previous Medical History 4. Previous Surgical History 5. Current Medications 6. Family History 7. Social History 8. Review of body systems Importance of EBP • Helps determine the effectiveness of the caregiver’s interventions or outcome measures. Principles of patient examination and evaluation • Examine and evaluate/ reexamine and reevaluate frequently • Establish baseline • Provide data and information to develop clinical diagnosis and prognosis • Measure the patient’s attainment of goals or functional outcomes • Provide data and information for use by other persons Guidelines for Patient Examination • Gather subjective and objective information and data • Observe the patient • Palpate patient areas • Test and measures • Cardiovascular /pulmonary functions • Functional abilities and performance and daily tasks • Mental and cognitive function • Review other reports and tests when available Communication • Primary function of life • Verbal communication and NVC Forms of NVC 1. Appearance 2. Body movements 3. Body positions 4. Facial expressions 5. Pantomime 6. Posture 7. Spontaneous response to stress 8. Touch Barriers to effective communication • Distance • Noise and environmental confusion • Inability to comprehend of the receiver • Inability interpret and understand technical, medical, professional terms, language and abbreviations • Inadequate amount of feedback • Complex messages • Cultural, gender, age difference • Illegible writings Safety Considerations • Hospital Codes • Code red-fire • Code blue-heart or respiratory arrest • Code orange-hazardous material spill • Code gray-combative person • Code silver-person with weapon • Amber alert-infant and child abduction • External triage-external disaster • Internal triage-internal emergency • Code name clear-to clear all code Medical errors • Patient safety primary goal and focus of each person, facility, and service area involved with patient care. • Type of errors 1. Sentinel 2. Potential adverse 3. Active 4. Latent Patient rights • Right patient • Right drug • Right time • Right route • Right dose
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