Patient record information gathered by healthcare

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3. Patient record – Information gathered by healthcare professionals from previous visits. 4. Technology – Medical history, physical exams & progress notes, Consultations, Reports of labs / diagnostic studies, Reports of therapies by other healthcare professionals, and Assessment Technology - machines that monitor patients 5. Other health care professionals – Such as Physicians, social workers and other healthcare professionals to learn about patient's health habits, patterns and responses to illness. Extremely important when patients transfer from one healthcare setting to another. Describe the purpose of nursing observation, interview, and physical assessment. Observation – conscious and deliberate use of the five senses to gather data Interview – Planned communication for a specific purpose Physical assessment – systematic examination of the patient for objective data to better define the patient’s condition and to help the nurse in planning care Obtain a nursing history using effective interviewing techniques. Four phases - 1. Preparatory phase 2. Introduction 3. Working phase 4. Termination Plan patient assessments by identifying assessment priorities and structuring the data to be collected systematically. Systematic guidelines specifically developed for a nursing assessment help ensure that comprehensive, holistic data are collected for each patient and lead easily to formulating nursing diagnoses. When the
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nurse internalizes such assessment guidelines, it is easier to focus on the patient during the assessment rather than worrying about what to assess next.
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  • Winter '19
  • Nursing, patient data, Assessment Technology

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