Professional Documents
Culture Documents
Communication
Communication barrier
Anything that gets in the way of
clear communication.
Physical disabilities
Psychological attitudes
and prejudice
Cultural diversity
Deafness or hearing
loss
Blindness or impaired
vision
Aphasia or speech
disabilities
Prejudice
Attitudes
Personality
Cultural Barriers
edema
Presence of rash or sore
Color of urine or stool
Amount of food eaten
Smell
Body odor
Unusual odors of:
breath, wounds,
urine and
stool
Touch
Pulse
Dryness
of
and temperature
skin
Perspiration
Swelling
Hearing
Respirations
Abnormal
body sounds
Coughs
Speech
Observations:
Observations
should be reported accuratelyuse facts and report what you saw, not the
reasons.
NOT-Mr. Ruiz is in pain.
INSTEAD- Mr. Ruiz is moaning and holding
his side.
Observations on a patients health record
(chart) should be accurate, concise, and
complete.
Observations:
Objective
Subjective
Objective
Assessment
Plan
SUBJECTIVE . These
are symptoms the patient
verbally expresses or as
stated by a significant other.
These subjective
observations include:
the patient's descriptions of
pain or discomfort,
the presence of nausea or
dizziness,
when the problem
first started, and
a multitude of other
descriptions of dysfunction,
discomfort, or illness the
patient describes.
OBJECTIVE These
objective observations
include symptoms;
that can actually be
measured seen, heard,
touched, felt, or
smelled.
Included in objective
observations are vital
signs such as
temperature, pulse,
respiration, skin color,
swelling and the results
of diagnostic tests.
ASSESSMENT is
the diagnosis of the
patient's condition. In
some cases the
diagnosis may be clear,
such as:
a contusion. However,
an assessment may not
be clear and could
include several
diagnosis possibilities.
SPt. states that she has always been overweight. She is very
frustrated with trying to diet. Her 20 year class reunion is next year and
she would like to begin working toward a weight loss goal that is
realistic. NKDA, NKA.
A medical office assistant asks a pt. if she has net her deductible.
The pt. doesnt answer. What should the medical office assistant do
next? Ask Why are you so embarrassed? Charge the full
amount of the bill Ask Do you understand what Im asking?Make a note on the chart that the pt. is uncooperative.
A Latino pt. comes to the ER and expresses concern about being
treated by a Caucasian physician. The health care worker should:
Allow the pt, to express his/her fears without being judgmental Tell
the pt. that the physician is a good one and he/she had nothing to
worry about Say nothing to the pt. but inform the doctor of the pts.
Hostility Find a Latino healthcare worker in the hospital who can
verify the doctors credentials to the pt.