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medical documentation healthcare patient care communication

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This document appears to be notes on medical documentation, patient client management, and related topics. It contains sections on SOAP notes, various considerations, community education, patient family education, and interprofessional communication.

Full Transcript

**6,7,8. Documentation** Why is Documentation Important? 1. a. 2. b. 3. c. 4. d. 5. e. 6. f. i. 7. 8. g. 9. h. 10. i. +-----------------------+-----------------------+-----------------------+ | ***Patient Client | ***Patient Client | ***SOAP Note***...

**6,7,8. Documentation** Why is Documentation Important? 1. a. 2. b. 3. c. 4. d. 5. e. 6. f. i. 7. 8. g. 9. h. 10. i. +-----------------------+-----------------------+-----------------------+ | ***Patient Client | ***Patient Client | ***SOAP Note*** | | Management Note*** | Management Process*** | | +=======================+=======================+=======================+ | History | Examination | **S**ubjective | | | | | | Systems review tests | | **O**bjective | | + measures | | | +-----------------------+-----------------------+-----------------------+ | Evaluation | Evaluation | **A**ssessment | | | | | | Diagnosis | | | | | | | | Prognosis | | | +-----------------------+-----------------------+-----------------------+ | Expected outcomes | Plan of Care | **P**lan of Care | | | | | | Anticipated goals | | | | | | | | Interventions | | | +-----------------------+-----------------------+-----------------------+ **SOAP** 1. a. b. - - - - - - 2. c. - - - - - - 3. d. i. 1. - Impaired sensation in C5 dermatome ii. 2. iii. 3. iv. 4. a. b. i. c. ii. d. iii. 5. e. iv. v. 6. f. g. vi. - - - - - - - - - - - - - - - - - - - - - - - - - - - - 4. e. f. - - - - - - Patient/Client Management Model 1. a. i. ii. b. iii. c. iv. v. 2. d. 3. e. vi. f. vii. 4. g. viii. ix. x. xi. xii. h. i. xiii. xiv. xv. xvi. xvii. 5. j. xviii. xix. xx. xxi. xxii. xxiii. 6. k. **Coding** - - - - - - - Effective Documentation \~ **BE OBJECTIVE AND FACTUAL** **→ Defensible Documentation Elements** 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. **[Electronic Medical Records (EMR)]** - **[Levels of assist]** - - - - - - - - **[Assistive Devices]** - - - - - - **[Weight bearing status]** - - - **[ROM]** - - - **[Vital Signs]** - - - - **[Miscellaneous ]** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - **9. Community Education** What is it? - - - - When? - Why? - - - - - **Audience Analysis** 1. a. b. 2. c. d. e. f. 3. 4. 5. 6. What Led to Their Health Behavior? - GOAL: To influence as many individuals to change! - - - - - **10. Patient Family Education** What Do We Teach? - - - - - - - - Our Goal: INFLUENCE HEALTH BEHAVIOR **[9 Principles for Effective Patient Education (Davis)]** 1. a. b. 2. c. d. i. ii. iii. iv. 3. e. 4. f. 5. g. v. h. i. 6. j. vi. 7. k. 8. l. 9. m. n. o. +-----------------------+-----------------------+-----------------------+ | **Patient Education** | **Questions** | **Steps** | +=======================+=======================+=======================+ | Home Exercises | - - - - | 1. 2. 3. | +-----------------------+-----------------------+-----------------------+ | Postural + Functional | - - - - | **Kinesthetic | | Training | | Comparative | | | | Training** (KCT) | | | | | | | | - - - | +-----------------------+-----------------------+-----------------------+ Family Education - - - - - - - - - - - - Child Education - - - - - - - - - **11. Interprofessional Communication** Why? 1. - - 2. - 3. With Who? - - - - - - - - When? 1. a. b. c. i. ii. iii. iv. d. v. vi. Advantages: - - - - - - - - Limitations - - - - - - Essential Communications - - - - - - - - Schwartz Center Rounds - - - - - - - **12. Learning Theory and Styles** Role as Educator is to Reflect on 1. a. i. 1. 2. 3. ii. b. iii. 4. 5. 6. 7. 8. 9. iv. c. v. vi. 2. d. vii. 10. 11. 12. viii. 13. ix. 14. e. x. xi. 15. 16. f. xii. 17. 18. 19. 20. 21. 22. 23. 24. g. h. i. 3. j. xiii. 25. xiv. 26. xv. 27. xvi. 28. 4. Forms of Learning 1. a. i. ii. iii. 2. b. iv. v. c. vi. 1. vii. 2. d. viii. 3. 4. ix. **Bloom's Taxonomy (KCA AES)** 1. 2. 3. 4. 5. 6. **Motor Learning** 1. a. i. ii. iii. iv. b. v. vi. vii. viii. c. ix. x. xi. xii. 1. xiii. 2. Psychomotor Learning: Massed vs. Distributed 1. a. 2. b.

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