CLIN 2505 Week 2 Lab - Patient

CLIN 2505 Week 2 Lab - Patient - I Dr. I I lPt....

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Unformatted text preview: I Dr. I I lPt. l___'_m_______..._____ CLIN 2505 Week # 2 Lab 0 This week’s lab will meet in C-HOP (1415 Barclay Cir); enter through the student entrance towards the rear of the building. I Student parking is limited to the yellow spaces only and is very limited, therefore, I recommend that you park on campus and walk (5 J minutes). 0 Dress in clinic attire and wear your student ID. You do not have to wear a blue jacket. 0 Report to your assigned room (numbers handed out week # l) 0 Report to the student lounge if you were not assigned to a room. 0 Notify a faculty clinician if you do not have a partner. 0 One student will play the role of “doctor” and the other “patient”. 0 The “patient” will complete the Assessment Rubric (attached) based on the “doctor’s performance”. Turn in all forms to the faculty clinician at the end of today’s exercise. Attendance will be taken from the Assessment Rubric form. 0 This rubric will not be a part of the grade, it is meant to guide and improve your skills. 0 The “doctor” will conduct a patient interview and Vital signs on the “patient”. Attempt to treat this as a real patient encounter. o A faculty clinician will periodically monitor your interactions and is there to assist you, so feel free to ask them questions if needed. 0 When you complete the patient interview and Vitals: o The “patient (evaluator)” should discuss the Assessment Rubric with the “doctor”. 0 And Notify the faculty clinician who will review the paperwork with you and the patient. 0 If time allows switch roles so that each student has the opportunity to conduct a patient interview. Additional forms are available from the faculty clinician. I: N n—t U 0—! : L1 0 >> l: 5 0 :53 0 H m E L1 :53 :1 {'3 : 05-1 a h 5 H Be patient, many students may finish at the same time and the faculty clinician will get to you as soon as possible. After the faculty clinician reviews your paperwork, they will keep the PGIQ, Health History Worksheets and the Assessment Rubrics. * Be sure that both CLINZSOS students names are neatly printed at the top of this form as well as your room number. Attendance will be taken from these forms. 9‘ I.__..__...___..._._...____ The Online Assignment: Narrative History Exercise 0 Part one is due at the end of week # 1. I 0 Be sure to work with your assigned file. 0 This is a course requirement; you will not pass this course unless you I complete all parts of it. _u—m—_—_m__— Review of Systems Skin Eyes Ear, Nose, MouthI Sinuses Lungs Cardiovascular Digestive Genitourinary Hematological Immunological Endocrine Musculoskeletal Neurological . Psychiatric Eris—*IQTHWDPPU? Ref. Mosby?s Guide to Physical Examination (pg. 24, 25) We, the clinic faculty and staff, are committed to serve our community in a professional clinical environment and to empower patients to actively participate in their healthcore. The Life University Clinics recognize and respect the self-aware, self-directed, self-maintaining, self-healing, and self-improving nature of life and living beings. If you have been involved in an auto accident or a work iniury please speak to one of the office assistants before completing this form. This section is be completed by the Staff. Date: Faculty Clinician: Intern Name: Intern No. SECTION 1 Personal Data Patient Name: First Last M.l. Prefers to be called Birth Date _/_/ [:l M [:I F Parent or Guardian's Name if the Patient is a Minor: Are you currently pregnant? D Yes D No I:l Maybe. Have you ever been pregnant? El Yes C] No Home Address: City: State: Zip: Phone: Home: Work: Mobile: E-mail: Current Employer Contact Phone: Work Address: City: State: Zip: Job Description Marital Status: [3 Single El Married El Divorced D Widowed Spouse/Partner Name: Spouse‘s Employer: Number of Children: Ages: Emergency Contact Person: Phone : Form: RPF 2010 Version 4.0 Revised March 15, 2010 Page 1 of 6 RD/mt ©Life University College of Chiropractic SECTION 2 Page 2 Reason for Care: I am here for a Specific Condition Yes E] No C] ifNo please go directly to SECTION 3 Primary Complaint Secondary Complaint Tertiary Complaint Briefly describe complaint: PAIN SCALE (CIRCLE) BEST WORST 012345678910 Is it constant? [:I Yes Comes&goes? EIYes Please check ALL that describe your current symptoms? C! Sharp D PlinS/Needles El Stabbing I:I Tingling El Dull I:I Numbness D Aching I:I Tightness El Pinching D Other Please check ALL that aggravate your condition? D Driving [:1 Breathing D Walking [1 Coughing [:J Sitting D Sleeping I: Bending El Working I:I Standing I:I ExerCIsmg I:I Bowel Movements D Other What makes your condition better? I:I Chiropractic I:I Stretching [:1 Rest I: Massage El Recumbent El Medication {:1 Sitting El Nothing D Standing D Other Have you had this current complaint in the past? [3 Yes [:I No If Yes, when? / / Have you seen any other healthcare providers for your current complaint? I:l Yes D No Briefly describe complaint : PAlN SCALE (CIRCLE) BEST WORST 0 1 2 3 4 5 5 7 8 9 10 is it constant? C] Yes D No Comes & goes? El Yes El No Please check ALL that describe your current symptoms? I:I Pins/Needles El Stabbing [:I Tingling D Dull D Numbness D Aching El Tightness I:] Pinching D Other Please check ALL that aggravate your condition? El Driving I: Breathing El Walking [:1 Coughing I:l Sitting D Sleeping I:I Bending El Working I:I Standing |:| Exercising I:I Bowel Movements D Other What makes your condition better? [1 Chiropractic D Stretching I] Rest El Massage El Recumbent I:I Medication I:| Sitting I: Nothing El Standing D Other Have you had this current complaint in the past? [:I Yes E] No If Yes, when? __/_/ Have you seen any other healthcare providers for your current complaint? El Yes I: No Form: RPF 2010 Version 4.0 Revised March 15, 2010 Page 2 of 6 RD/mt Briefly describe complaint : PAIN SCALE (CIRCLE) BEST WORST 012345678910 Is it constant? C} Yes I: No Comes & goes? El Yes I: No Please check ALL that describe your current symptoms? El Sharp I: PinS/Needles l:| Stabbing [:| Tingling |:| Dull D Numbness D Aching |:| Tightness |:| Pinching D Other Please check ALL that aggravate your condition? I:I Driving [:I Breathing I:I Walking I: Coughing I:I Sitting D Sleeping I:I Bending 1:] Working E Standing I:I ExerCIsmg Bowel Movements 1:] Other What makes your condition better? El Chiropractic I: Stretching El Rest El Massage E] Recumbent I: Medication E] Sitting I: Nothing [3 Standing B Other Have you had this current complaint in the past? D Yes D No If Yes, when? __/ / Have you seen any other healthcare providers for your current complaint? I: Yes E] No ©Life University College of Chiropractic Page 3 Patient Name: Date: File #: SECTION 3 Health Habits & Lifestyle Please answer the questions below. EXERCISE DIET DO you exercise? DO you have a healthy diet? I:IYes DNO I:IYes BNO How often do you exercise? How many serving 5 of fruits & __ days/week_ Hours/day vegetables per day? # ALCOHOLITOBACCO/RECREATIONAL DRUG USE? Do you use any of the above? El Yes D No How many cigarettes do you smoke? /day or {wk Do you use smokeless tobacco? I:IYes BNO How much do you use a day? Stretching /Fiexibility DYes EINO Running / Treadmiil/ Walking I: Yes D NO Rowing / Swimming El Yes D NO Competitive Athlete D Yes El NO Pilates [Yoga 1:] Yes I:I No Group Exercise E] Yes I:I No Weight Lifting DYes Duo How many 80:. glasses of water per day? # Do you drink caffeinated beverages? El Yes D No How many per day? if Cans or pouches /day Do you have history of alcohol use? I:IYes I:I No #drinks lday /wk 1 “drink” is equal to 12 oz. can of beer, 1.5 oz. liquor, 80 proof, 5 oz. wine. Please List Food Allergies? Have you ever had an eating disorder? CI Yes D No DAILY STRESS LEVEL SCALE Low High 012345673910 SLEEPING PATTERN Hours ofsleep per night? hours OTHER: Please list- Please circle appropriate sleep quality. Excellent Good Fair Poor Have you ever sought help for a mental health issue? DYes E] NO Sleep interrupted How long? _____ wks, _times/ night mths, Yrs SECTION 4 Personal Health History Please mark a_ll issues below that you have currently or have had in the past. C = current P = past MUSCLE [JOINT EYES/EARS/THROAT SKIN C P CARDIOVASCULAR C P GENERAL C P C P C P Easy BruisingC P Blood Pressure C P Food Allergy C P Arthritis C P Thyroid C P Psoriasis/Eczema Irregular Heart Beat C P Dizziness C P Lower Back Pain Hearing Difficulty C P Pom. Circuyation C p Headaches C p _ _ C _ _ C P HIVES C P URINARY c p infections C P Bursms C mm” C P 5km Ai'ergV C P Kidney c P iNFECTIOUS DISEASES SCICCC CCIC C DIGESTIVE C C Itcmng C P Difficulty Urinating C P C P Hip Pain C Stomach C P ' F W . C , w REPRODUCTIVE c P “’V C P 0° 3'“ 'ntestma' C P PULMONARY c P Hepatitis c P N k P _ C Menstrual C P ec am 03'0" C P Difficulty Breathing Tuberculosis C P Pregnancy C P Headacbe C INTERNAL c P C P Shoulder Pain - mm c P PmState C P C Liver C P A th C P Venereal Disease C P ENDOCRINE C P Gall bladder C P 5 ma . NEUROLOGICAL C P Arm Pam C pancreas c p Seasonal Allergies PSYCHOLOGICAL C P Wrist Pain C C P Form: RPF 2010 Version 4.0 Revised March 15, 2010 Page 3 of 5 RD/mt ©Life University College of Chiropractic Page 4 Please list all ofthe medications you are taking including over the counter medications, herbs & vitamins and nutritional supplements. ifnone please write: None Name/ Dose / Frequency Name / Dose / Frequency Medication Allergies — Please list all below SECTION 5 Please list ALI. accidents, injuries, surgeries & hospitalizations. if none please write: None Accidents, Injuries, Fractures (Dates) Surgeries (Dates) Hospitalizations (Dates) Please list all of your doctors and healthcare providers including previous Chiropractors Name: Phone # Name: Phone it Name: Phone it SECTION 6 Famiiy History Please mark the appropriate box with an X. HISTORY Father Brother/Sister Grandmother Grandfather Diabetes Heart Problems High Blood Pressure High Cholesterol Kidney Problems Cancer Headaches Anemia Arthritis Auto immune Disorder Obesity Other DDDDDDEDDDDD DDDDDDDDDDDD DUDDDDDDDDDD El D D E! El D E] El D D D D [:1 El E El III B E El El D Form: RPF 2010 Version 4.0 Revised March 15, 2010 Page 4 of 6 RD/mt ©Life University College of Chiropractic Page 5 Patient Name: Date: File #: 1. Are you an employee, or related to an employee at Life University? D Yes El No Relationship: 2. Are you a student, or related to a student in any program at Life University? CI Yes CI No Relationship: 3. Are you a student, or related to a student in a DC Program? D Yes El No Relationship: 4. Do you or a relative plan to enroll as a student in a Doctor of Chiropractic Program? C] Yes El No if yes, When: and Relationship: 5. If you answered yes to 2, 3 or 4: Student’s Name: Student ID: Consent for Chiropractic Care in Life University Clinics Chiropractic care is based on clinical evidence of vertebral subluxations and not the presence or absence of pain, abnormal range of motion, or abnormal spinal curves. By the use of specific analysis and spinal adjustments, the goal of chiropractic is primarily to reduce/correct spinal subluxations. - The Life University chiropractic clinics are teaching clinics. o The chiropractic assessment and chiropractic care provided in the Life Clinics may occur in an open environment. a In some situations, your care will occur in an open environment and personal health information (PHI) may be subject to incidental exposure by others in the clinic setting a I understand that my records and/or x-rays are the property of Life University and will be used for teaching and research purposes and if at anytime I request a copy of my records and/or x—rays there will be an additional charge for copying them. 0 I authorize Life Clinics and its agents to administer care as needed, as indicated from examination findings. 0 i authorize Life Clinics to release information to my doctor and/or insurance company. 0 I understand that if I am in iitigation for any accident my settlement may be jeopardized by the fact that a student is rendering my care in this clinic. 0 A parent or an approved individual MUST accompany their minor child on every visit to the clinic. 0 I acknowledge that l have read Life University’s Notice of Privacy Practices (or had the opportunity to read it ifl so choose). I have received a summary of Life University’s Notice of Privacy Practices and acknowledge that i may have a personal copy of the entire Notice upon request. a i consent to the use and or disclosure of my protected health information as Specified in Life University’s Notice of Privacy Practices. I have read and understand the above. Patient Signature Relationship to Patient Date (custodial parent or legal guardian if patient is a minor) Witness Signature Date Print Clinician Name - # Faculty Clinician Signature Date Form: RPF 2010 Version 4.0 Revised March 15, 2010 Page 5 of 6 RD/mt ©Life University College of Chiropractic Page 6 Office Use Only _ R Regular | Insurance T Transient TS Transient DC Student C Child E Veteran P Employee 0 Employee Family G Gratis Gl Partial Gratis GA Alumni GF Alumni Family LS LU Student LF LU Student Family GM Medicare NS College Students EM Active Military E! E] D D D D E] D D How did they hear about us? 11‘ Website D Friend / Family member Name: D Intern Name: l:l Life Center for seniors Name: |:] Health Fair Name: [:1 Other Name: PHOTO ID Form: RPF 2010 Version 4.0 Revised March 15, 2010 Page 6 of 6 RD/mt ©Life University College of Chiropractic . The ur ose of this assessment is to I “Patient” - p p mum—r provide meaningful feedback to the . Student “doctor” , student. It will not affect the student’s Date grade unless it is not comnleted at all. I Please rate the interviewer for each step of the interview. (adapted from The Patient 's Story: Integrated Patient-Doctor Interviewing. East Lansing, ML: Robert C. Smith) Step # 1 Set the stage for the interview 1) Welcome the patient 2) Use the patient’s name 3) Introduce self and identify Specific role 4) Ensure patient readiness and privacy 5) Remove barriers to communication 6) Ensure comfort and put the patient at ease D insufficient D mediocre D good D excellent ' 5? explain . . Step # 2 Establish Chief Complaint and Agenda 1) Indicate time available 2) Indicate what needs to be compleatég’iifiithfiat time 3) Obtain list of patient complaints ‘ 4) Summarize and finalize the agenda?“ ' accomplish in the tippe allotted. eensuige accuracy of the PGIQ *‘ate what you can realistically es): 5"“ D insufficient U mediocre good D excellent t“??? explain m—gf—-——f a as: Step # 3 Elicifié‘ is“ patient’s story - Encourage? apatient to express themselves 1) St 4 with Open-ended questions* 2) Use “non focusing “open ended skills* (active listening) 3) Don’t interrupt D insufficient D mediocre D good D excellent explain Practice Lab Assessment Rubric Step # 4 Define the patient’s story 1) Use “focusing” open-ended skills* 2) Followed by close-ended questions* to fill in the details i. Moving from general to specific ii. Questions with a graded response* iii. Forced—choice questions* if patient has difficulty expressing themselves iv. Avoid leading questions and multiple questions 0 Develop the more general personal/psychosocial context of the symptoms 1) Use focusing open—ended skills such: How has this affected you? or What do you thing is going on? i 2) Emotion seeking questions* (when appropriate) i. Be aware of non verbal cues . . . , gfilllgviha 3) Emotlon Handling skills * (when appropriate) 3%? g at? 123st . ,5: "' its insufficient D mediocre D good D dkggellent explain I?!” I ,wflilfifi I? _ ; —~%W_—~—-«é—a—t——————~w_§ 4,, I. Step # 5 Complete the Interview and transitioning to the exam 1) Briefly summarize thegégégl checking for accuracy with the patient 2) Repeat steps # 3 and 4 ch complaint 3) Obtain additional historicafiiilormation (Comprehensive Hx) : b. Past history, gaggily history, Occupational, ROS, current health status and health risk f :ctors (Exercise, diet, alcohol, tobacco, drugs). 4 Transitiont ’ mating? ) rain-W were '3 insufficient mediocre D good D excellent - Proposed timeline Preparation HPI Steps 1 & 2 Steps 3 & 4 Completion & Transition Step 5 l — 2 minutes 5 — 10 minutes ...
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CLIN 2505 Week 2 Lab - Patient - I Dr. I I lPt....

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