R. John Brewer NREMT-P Dental Education Inc. PATIENT ASSESSMENT

Similar documents
R. John Brewer EMT-P Dental Education Inc. PATIENT ASSESSMENT

Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio

Amarillo Surgical Group Doctor: Date:

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6

Inner Balance Acupuncture

Please describe, in detail, when the symptoms began:

Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT

Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)

Hospital he hospital is located near the interchange of highway 217 and (US 26).

PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /

City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,

MCKAY UROLOGY LINCOLNTON OFFICE PATIENT HISTORY FORM

Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX Phone (903) Fax (903)

WEEK. OSPAP Programme. Respiratory Examination & History. Slide 1 of 49 MPHM14 OSPAP Clinical Skills

Laser Vein Center Thomas Wright MD Page 1 of 4

Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire

Patient Medical History Form Pre-Surgical Bleeding History Questionnaire Name:

Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).

Where is your pain located? Please use the diagram below to indicate where most of your pain is located.

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS

Scottsdale Family Health

CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)

Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?

Pre-Admission Testing Questionnaire

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY

PATIENT REGISTRATION

New Patient Specialty Intake Form Department of Surgery

PATIENT HISTORY FORM

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

New Pulmonary Patient Questionnaire. Name Age Date. General Medical History

REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL

Questionnaire for Lipedema Patients

Medical History Form

NEW PATIENT INFORMATION FORM

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

CHRISTIANA SPINE CENTER NEW PATIENT QUESTIONNAIRE

Address Street Address City State Zip Code. Address Street Address City State Zip Code

Please list any treatments you have previously had for current illness. (Physical Therapy, Surgery, Radiation, etc.)

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166

PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.

Headache Follow-up Visit Form

NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR

DATE OF BIRTH: MELANOMA INTAKE

+ Color Change - + Hearing Loss - + Apnea - + Enuresis (urine - + Tremors - + Rash -

Balance and dizziness questionnaire

Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:

NEUROLOGICAL SURGERY, P.C.

Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code

Integrative Consult Patient Background Form

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

Laser Vein Center Thomas Wright MD RVT Page 1 of 4

Joseph S. Weiner, MD, PC Patient History Form

Effective Case Presentations

Please list all medications you are currently taking (include aspirin, vitamins, hormones), Dosage, and Frequency.

New Patient Pain Evaluation

Eastern Body Therapy

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

RHEUMATOLOGY PATIENT HISTORY FORM

Name. Date of Birth. Primary Care Doctor? Who is the Doctor that referred you to us? Name of person completing this form?

3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:

EVALUATION FORM FOR MALE FACTOR SUBFERTILITY UT ERLANGER MEN S HEALTH

Health History. Tests and Procedures: Test: Date: Location: Provider: Abnormal: Results/Notes: Monthly self breast exam. Last mammogram (female)

725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)

Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program

PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA

Pain Management Questionnaire

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

History Form for Exceptional Home-Based Care

UnityPoint Clinic - Cardiology

PLAS/RECON SURGERY PATIENT HEALTH HISTORY

Allina Health United Lung and Sleep Clinic

MEDICAL DATA SHEET For Patients 18 years of age and older

Sleep History Questionnaire

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?

Health Intake Form. List your top five concerns or reasons for requesting your appointment with Dr. Weiss

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

Aspire Pain Medical Center

Georgia Northside Ear, Nose, and Throat, LLC

PATIENT INFORMATION SHEET

HEMATOLOGY/ONCOLOGY PATIENT INITIAL HISTORY. Name Age Date. Physician to who report is to be sent

Obtaining an Interval History

Patient History Form

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

New Patient Questionnaire HIP Adult Reconstruction & Joint Replacement

The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:

Welcome to About Women by Women

Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY

NEW PATIENT HEALTH HISTORY

Holistic Health Care New Patient Intake Form

NEW PATIENT INFORMATION FORM

Placer Private Physicians: Patient Health Questionnaire [2]

Pediatric Case History Form

General Internal Medicine Clinic - New Patient Questionnaire

Patient Intake Form for Allegany Ear, Nose, & Throat

Transcription:

R. John Brewer NREMT-P Dental Education Inc. PATIENT ASSESSMENT

Patient Assessment Patient assessment is made up of two parts - History - Physical Exam

Patient assessment In medical cases obtaining an adequate history is as important as, maybe even more important than the physical exam. The ability to elicit a good history is the foundation for providing good care. Good communication is key!! Ask open ended questions.

Patient assessment Listening is an important part of the interview. If you listen to the patient, they will tell you what is wrong. To be a skilled clinician you must be a good listener.

Patient history There are several components to a comprehensive history. This should be done in a systematic order. In practice you should be flexible and select components that apply to your patients situation and status.

Chief Complaint Defined as the pain, discomfort or dysfunction that caused your patient to request help. Ask open ended questions. Report and record patients chief complaint in their own words.

Present Illness The chief complaint needs to be explored in greater detail. A practical template for exploring the events is the mnemonic : OPQRST-ASPN

Present Illness O Onset P Provocation/Palliation Q Quality R Region/Radiation S Severity T Time AS Associated symptoms PN Pertinent Negatives

Onset Gradual or sudden What was patient doing when symptoms began.

Provocation/Palliation What provokes symptoms(makes worse) Does anything palliate symptom(make better)

quality How does the patient perceive pain or discomfort. Does patient call pain crushing, tearing, crampy, dull, sharp etc Quote patients description in report.

Region/Radiation Where is the symptom? Does it move anywhere else? Determine if actual pain or is it tenderness(pain upon palpation) Note any pain that may be reffered.

Severity How bad is the Symptom The pain scale is very important 0-10.

Time When did symptoms begin? Is it constant or intermittent? How long does it last? How long has it affected your patient? When did previous episodes occur? How is it the same/ how is it different

Associated symptoms What other symptoms commonly associated with the chief complaint can help you make diagnosis. Ex. Short of breath, nausea, with someone having chest pain.

Pertinent Negatives Are any likely associated symptoms absent? Absence is as important as Presence. Note any element of the history or physical that does not support a suspected diagnosis.

Past Medical History The past history may provide significant insights into your patients chief complaint and your diagnosis. Some of the important things we need to know are: - Adult diseases, recent accidents or injuries, - Surgeries,hospitalizations.

Current Health Status Current health status assembles all the factors in your patients present medical condition. Some of the important infromation is as follows -current meds - allergies -alcohol, tobacco, drug use -diet

Current health status - Immunizations - Sleep patterns - Exercise and leisure activities - Environmental hazards - Family history - Home situation - Daily life

Core Questions to ask The are 10 core questions that should be included on any medical history form. 1. Are you under a physicians care or have you been during the past 5 years, including hospitalization, and surgery. - Many problems may be identified if this question is worded correctly and properly followed up.

Core Questions 2. Are you currently under a doctors orders or taking any medications, including birth control pills, over the counter drugs, herbal supplements, homeopathic preparations. This question elicits more information about the severity of the patients problems than any other part of the medical history.

Core questions 3. Do you any allergies or are you sensitive to any drugs or substances? Specifically ask about penicillin, novocaine, aspirin, latex, or codeine.

Core Questions 4. Have you ever bled excessively after a cut, wound or surgery? Have you ever received a blood transfusion. Serious bleeding problems usually require treatment that the patient recalls.

Core Questions 5. Are you subject to fainting, dizziness, nervous disorders, seizures or epilepsy? This question may uncover patients who -pass out at sight of syringe or blood. - meniere syndrome - psychiatric illness - seizures

Core Questions 6. Have you ever had any difficulty breathing? This includes asthma, emphysema, chronic cough, pneumonia, Tuberculosis, or any other lung disorder? Do you use any tobacco products? Do you snore or have been diagnosed with sleep apnea.

Core Questions 7. Have you or your family members ever had any anesthesia related problems. This question may help identify difficult airways, or patients at risk for MH

Core Questions 8. Do you have heart disease or a history of chest pain or palpitations? You may want to include dizziness with exertion, syncope during or following exertion.

Core questions 9. If your staff is asking these questions, they should include the following Is there anything you would like to discuss alone with the Doctor.

Core questions 10. Do you currently use or have a history of using recreational drugs. -Hopefully this will illicit an honest answer.

Additional questions When anesthesia is going to be given, it is important to ask when the patient ate, or last drank fluids. The presence of a responsible party to transport the patient home. With females ask about pregnancy.

Review of Symptoms The review of symptoms is a series of questions designed to identify problems your patient has not mentioned. It is a system-by-system list of questions that are more specific than those asked during the basic history.

general What is patients usual weight, have their been any changes? Has there been any weakness, fatigue, or fever.

Skin Is there any rashes, lumps, sores, itching, dryness, color changes.

HEENT Head, Eyes, Ears, Nose and throat. Does the patient have any headaches, any nausea, recent head trauma, vertigo. Any blurred vision, spots, flashing lights, Sore throat, difficulty swallowing

Respiratory Does patient have any wheezing, coughing up blood, asthma, COPD, Pneumonia,

Cardiac Heart Problems hypertension MI Palpitation Dyspnea

G.I. Nausea, vomiting Bloody, tarry stools Abdominal pain

neurologic History of fainting, blackouts, seizures, speech difficulty, vertigo, weakness, paralysis.

Endocrine History of thyroid problem Excessive sweating Cold intolerance History of diabetes Excessive thirst, hunger, urge to urinate

Physical Exam Actually begins when you first set your eyes on the patient. You can immediately assess the following: - General appearance - level of consciousness - breathing effort - skin color - skin temperature

Appearance Look good vs Look bad Level of consciousness Signs of distress Skin color Posture, gait Dress, grooming, hygiene Odors Facial expression

Vital Signs Pulse Respirations Blood Pressure Temperature Pulse oximetry Capnography Cardiac monitoring Blood glucose

Examination Techniques There are four techniques of the physical exam. Inspection Palpation Percussion Auscultation

Inspection The process of informed observation. A simple non invasive technique often taken for granted. One of the most valuable ways to assess.

Palpation Using your sense of touch to gather information.

Auscultation Listening with a stethoscope to chest, abdomen. Difficult to master.

Percussion NOT Reliable

Summary of Data Required in the Office Record. - A written signed and dated medical history containing the vital statistics and core medical information. An exam chart with the proposed procedures clearly indicated and the probable complications written on the record.

Summary of Data required in the office record ASA physical status Consent forms If indicated appropriately labeled x-rays Anesthesia record should document the patients status at time of discharge.(aldrete scale)

Summary of data required in the office record A time oriented anesthesia record indicating anesthetic agent used, amounts, times given, and if 02 was administered. Preoperative, postoperative, and discharge vitals should be recorded. Any unusual reaction/complication needs to be documented.

Summary of Data Required in the office record A record of prescriptions given. A duplicate copy of the prescription is preferred because it gives complete data on dosages, instructions for taking the meds, and the total amount of the medications prescribed. ***You must have good documentation***

Summary We must remember the Six Rs -Read the scene - Read the patient - React - Reevaluate - Revise the management - Review your performance

Read the scene Evaluate why patient is having a problem

Read the patient Identify life threats Observe patient (LOC, color, C/C Vital signs

React Treat life threatening problems Determine other serious conditions

Re evaluate Conduct a focused and detailed physical assessment. Note response to interventions

Revise management plan Change or stop interventions that are not working, making condition worse.

Review Review your performance of yourself and staff. Be honest Look for better ways to handle emergency CISM

Clinical decision making is essential when an emergency arises in the office. Your ability to gather information, analyze it, and make a critical decision on treatment, may make the difference between life and death.

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback