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Clinical encounter
Test 2
| Info | Description |
|---|---|
| Stage 1: Patient Encounters begin with reviewing the patient’s chart | Contains: Name+Age+Weight+Height+Chief complaints+ history of present illness (HPI) + Past medical history+ Admission note + advanced directives+ Physician orders + Progress notes |
| Stage 2: Introduction | 3 Zones of Space 1: Social Space 2: Personal Space 3: Intimate Space |
| Social Space | *4–12 ft from the patient * used for introductions and formal talk * do not discuss private matters |
| Personal space | *1 ^ 1/2 - 4 ft * good for personal discussions including the patient interview |
| Intimate Space | *0-18 inches * used to perform a physical examination * Watch for patient response in this area |
| Introduction | Introduce yourself to the patient - provide your name - your professional role - purpose of the visit |
| Confirmation of Patients identity | - check patients ID bracelet - name - DOB - MRN |
| Stage 3: Initial Assessment | Visual assessment begins when you enter the room |
| What can be observed? | - patients visual and general appearance - patient’s response, level of consciousness, appropriateness to questions - assess for clinical urgency - cultural differences - barriers |
| What can be assessed for urgency | - ventilation: get rid of O2 - oxygenation: deliver oxygen to ourselves - circulation: pumping ability of the heart; cycling thru - perfusion: blood being able to get to our cells and body |
| Stage 4: Patient Interview | Identify the patient problems/ symptoms |
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