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:
loss of self worth/image: touching pt to signify acceptance but do it in a professional manner (types of touching)
for emotional support
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)
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
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)
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
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:
clinician ordering exam
exam performed by name and views
radiologist's recommendations if any
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:
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
date of birth
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)
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 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?
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)
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)
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)
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
d. preparatory depression
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
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?
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"
Fluoroscopy procedure reports
Infants- Age and what to keep in mind when dealing with them. In the article, "Imaging Kids"
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