NURS 6512 Midterm Exam Review (Week 1-6) Building A Complete Health History 1. Communication techniques used to obtain a patient’s health history Courtesy, 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) 2. 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)
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