Code of Nursing
- Geneva 1973
- Patient has right to treatment regardless of race, creed, age, sex, political, or social value
What must you do and keep in mind when dealing with a differently abled patient?
- avoid term "disabled"
- all rights and freedoms are to be universally extended. full equality
Patient losses. HCP must consider:
- "abnormal state"
- loss of self worth/image: touching pt to signify acceptance but do it in a professional manner (types of touching)
- for emotional support
- for emphasis
- for palpation
- loss of daily schedule
- loss of independence
- major change in lifestyle
- loss of privacy-patient wearing down, give body samples
Communication. Key point
radiologic technology is a people-oriented, hand on profession that requires proficiency in a wide variety of communication techniques
adolescents- age related factors and what should we keep in mind when dealing with them? (Lecture)
- 10-25 years
- modesty becomes very important. middle adolescents want to be treated like adults regarding their own bodies
What is the acronym that hospitals are adapting to and name a hospital
- Thank you
Florence Nightingale's Plegde
- taking care of someone outside your family
- 1. Keeping medical confidence
- 2. Do no harm
Mature- age related factors and what should we keep in mind when dealing with them? (Lecture)
- 65 years and older
- young-old: 65-74 years. healthy and active
- old-old: 75-84 years. transitional
- oldest-old: 85 years+. frail and infirm
- treat all adults with dignity and respect
Toddlers- age related factors and what should we keep in mind when dealing with them? (Lecture)
- 1-3 years
- use simple words/commands
How to achieve harmonious interaction with your patient
- establish good verbal communication
- assess patient's condition and ability to comply with the requirements of the exam
- preserve patient's sense of privacy and modesty
- establish and maintain patient's sense of comfort
Young adults and middle aged- age related factors and what should we keep in mind when dealing with them? (Lecture)
- 25-45 years and 45-65 years
- treat all like adults
What must you do with a combative patient?
- be fast, efficient
- be professional at all times
- be in control of the situation
- refuse to do the exam if patient will not cooperate or if the become too abusive
What must you do with a frightened patient?
- explain, explain, explain
- answer their questions/concerns first before proceeding with the exam
- give extra care and attention
What are the exceptions to needing a signed medical release (generally med-legal)?
- communicable diseases- TB, STD
- child/elder abuse
- worker's comp
What is the storage requirement in California law for the handling/storage of the health record?
- adult- 7 years from date of last service
- minor- age of majority (usually 18) plus 1 year
- med-legal liabilities (work comp) indefinitely
In medical records in radiology, the radiology report must include:
- patient's name
- x-ray/medical #
- clinician ordering exam
- exam performed by name and views
- radiologist's recommendations if any
- radiologist signature
What are the two medical information management digital imaging systems?
- RIS- radiology information system
- PACS- picture archieving and communication system
- 13th century, Jewish philisopher who wrote on the relationship between medical issues to Jewish law
- sees patient in pain and sickness but has dignity and worth
What does HIPAA stand for and what is it?
- Health insurance portability and accountability act
- it sets specific standards for electronic transmission of health information. Violations result in penalties and sanctions.
What must you do with an elderly patient?
- take your time, give them time to react to your direction
- treat them with the respect they deserve, not like children
- keep your directions simple, give them extra attention
- Writings around 4th century B.C. in Greece which explore philosophical aspects of medicine(doctors)
- 1. Do no harm
- 2. Keep confidences shared by one's patients
- To assist patient in regaining "normal state" and minimize losses. Your main tools are:
- your sense of concern and desire to help
- effective communication skills
An exchange of information, ideas, or feelings between a source and a recipient. being able to relate to others and sharing something in common. Trying to make a connection
In medical record in radiology, X-ray storage jacket must include:
- patient's name
- x-ray/medical #
- date and name of exam
- name of clinician ordering exam (optional)
- preliminary and final radiology report
What is the definition of the Health Record?
permanent account of all patient care information that applies to that individual
What is the function of the Health Record?
Documents pertinent information of the assessment and treatment of the patient
In medical records in radiology, flash card must include
- patient's name
- date of birth
- x-ray/medical #
- name of clinician ordering exam
- name of exam ordered
- date that exam was done-extremely important, must be accurate
What is the philosophy of Handling/Storage of the Health Record?
- health records are legal documents that must be conformed to both state/federal laws and accreditation requirements
- managed must be done in an organized fashion under the direction of a skilled medical records practitioner
- access to PHI must be limited and pretected by confidentiality
What does PACS stand for and what is it?
- Picture Archiving and Communication System
- allows for medical images to be interpreted and stored in digital form without using film. consists of:
- 1. CRT monitor to display the images
- 2. network so images can be easily shared
- 3. a storage system like optical disk-no more film library
What does RIS stand for and what is it?
- Radiology Information System
- houses all demographics information of the patient who is having the procedure
- patient's data gets into the system when they checked in at the reception desk or when tech accesses HIS data
- data is used to ID patient's radiograph, create billing forms, etc
- "coordinates" patient information to match with patient readiograph images
What consists of the Medical Records in Radiology?
- flash cards(non digital)
- x-ray stoarge jacket (non digital)
- radilogy report
- billing/charge slip
What does JC formerly known as JCAHO stand for?
Joint Commission on Accreditation of Healthcare Organizations
In medical Records in Radiology, billing/charge slip must include:
- all service rendered including supplies used for a given exam
- all exams/procedures are given codes ICD-9-CM and CPT-4 to help with billing and dollar reimbursement
- completing the bulling slip is usually the responsibility of the technologist who performed the procedure
- must know your department's policies regarding how patients are billed for procedues
Patient's rights. History, Recent, Today
- 1. Hippocratic Oath
- 2. Maimonide's Oath
- 3. Florence Nightingale's Pledge
- Recent: Code of Nursing
- Today: Patient's Bill of Rights
What are the six communication components?
- The message- what you wish to convey
- The instigator- source of communication (you)
- The channel- vehicle to carry the message (writting, spoken, pantomime)
- The receiver- the person who is to get the message
- The context- set of circumstances surrounding the message. patient may not understand message
- Feedback from recipient- sign of understanding that verifies the correct message was received
What are the points that interfere with good communication?
- Personal attitues and biases- your own set of beliefs, prejudices, and values
- Inability to speak your patient's language
- Your own mind set- how you perceive yourself and your job
How do you communicate nonverbally?
- Facial expressions and body language are very important. Patients should see agreement between what you say and do
- Be attentive, truly listen to your patient
- Don't show anger, disapproval, negative emotions, revulsion
- Be calm, professional, caring, interested
- Avoid any act of misunderstanding
What kind of interview do we conduct with our patients?
Information interview. It's purpose is to get and give information
What is ePHI?
Electronice version of any protected health information
What is PHI?
Protected Health Information
What must you do or keep in mind when dealing with a pediatric patient?
- Acknowledge parents first and explain procedure
- Allow or not to allow parents to accompany patient (may help, may not help)
- Eye to eye contact with patient at their level
- Try to have child understand "you are getting your picture taken"
- Be honest- if it will hurt, tell the truth
- Be fast, efficient- have everything ready
- Use immobilization devices effectively
- Do not let the crying, kicking, screaming interfere with your functions
What must you do or keep in mind when dealing with a demanding/critical patient?
- Be professional
- Be fast, efficient
- Be very courteous
What is an interview? In the article, "Patient Interviews"
Any type of planned communication between two parties that involves the asking and answering of questions
What is a turn-about or interchanging of roles? In the article, "Patient Interviews"
When the patient is the one asking the questions. A good interviewer will allow this interchange to occur more than once during an interview and even will encourage a patient to ask questions and voice concerns.
What are the 7 challenging patient types?
- Terminally Ill
- Differently abled
To establish good verbal communication with your patient, you must:
- Introduce yourself- state name and role
- Explain to the patient:
- a. what the patient is having done
- b. what you are going to do with the patient
- c. what the patient is expected to do
What are the rolse of patient interviews? In the article, "Patient Interviews"
- We must learn interviewing through observation and trial-and-error. There are no classes or practice sessions.
- The entire exam consists of an extended patient interview, with pauses in between for technical procedures.
How must two parties establish their relationship? In the article, "Patient Interviews"
With the medical professional taking the role of the interviewer and the patient (or family member) as the interviewee.
Infants- age related factors and what should we keep in mind when dealing with them? (Lecture)
- Birth-1 year
- likes to be held in familiar position. Responds to facial expressions, body movements
Schoolchildren- age related factors and what should we keep in mind when dealing with them? (Lecture)
- 5-10 years
- Can think logically, however, have fear of bodily injury, separated from loved ones
Preschoolers- age related factors and what should we keep in mind when dealing with them? (Lecture)
- 3-5 years
- Must be actively involved in to maintain their short attention span
What must you keep in mind when dealing with terminally ill patients?
- Patient has closed awareness- you may not know if patient is aware of their condition.
- Patient has open awareness- If patient is fully aware, they may exhibit:
- a. denial and isolation
- b. anger
- c. bargaining
- d. preparatory depression
- e. acceptance
- Elizabeth Kubler-Ross
What are the subjective and objective components of The Health Record?
- *patient is the source of this info. Example: CC (chief complaint)
- *also contains important personal demographics
- *history data
- Objective: contains the "medical" information about the patient. Example: physical exam results, labs, x-ray reports.
What does HIS stand for and what is it?
- Hospital Information System
- Electronic inpatient information including demographic data
For medical records in radiology, request/requisition must include:
- Patient's demograhic information
- Clinician ordering exam
- Specific exam(s) ordered
- Diagnosis or "reason for film"
What are the types of filing systems for the handling/storage of The Health Record?
- Alphabet by patient's last name
- Numeric: SS#, terminal digit system, chronological
- Color coded
- Electronic- in HIS
What are the JC requirements?
- All services given to patient must be documented/charted
- JC requires health records to include patient data, medical history, report of physical exam findings, diagnostic/therapeutic orders and tests, clinical observations, eveidence of appropriate informed consent, conclusions at termination of treatment
- Approved abbreviations only
- Corrections/amending- must line out, write correct word and "error" on top, initial and date
What are the 3 parts in the interview process? In the article, "Patient Interviews"
Opening, body, and closing
What are the 3 interpersonal dynamics of an interview?
- Establishing the proper level of control
What are the 6 important quality documentation guidelines? In the article, "Writing it Right"
What are the 4 types of documents that technologists typically encounter during the course of patient care? In the article, "Writing it Right"
- X-ray requisitions
- Fluoroscopy procedure reports
- Incident reports
- Consent forms
Infants- Age and what to keep in mind when dealing with them. In the article, "Imaging Kids"
- Birth-18 months
- Patients fear being seperated from a parent
- Parents should stay in the room as long as they can
- a calm, soothing voice
- a pacifier or bottle
- toys with lights and sounds
Toddlers- Age and what to keep in mind when dealing with them. In the article, "Imaging Kids"
- 18 months-3 years
- Children at this stage still explore the world through their mouths and begin to explore through play
- a calm, soothing voice
- familiar objects from home
- puppets, magic wands
- books with lights and sounds
- blowing bubbles or feathers
Preschoolers- Age and what to keep in mind when dealing with them. In the article, "Imaging Kids"
- Beginning to use concrete thinking
- They like to be independent so give them choices such as which arm when taking their blood pressure
- Distract them with a TV, dolls, more detailed information, everything from the infant stage
School age- Age and what to keep in mind when dealing with them. In the article, "Imaging Kids"
- 5 years and up
- begins thinking logically
- be honest and protect their privacy
- talk at their level, eye to eye and do not talk down to them
- distraction methods: everything used from the infant stage, "I Spy" books, breathing techniques such as blowing bubbles