When a patient presents to a clinician the initial data include?
Two Patient Identifiers for Every Test and Procedure. The Importance of Being Identified by the Patient Care Team with Two Forms of Identification. Identifying patients accurately and matching the patient’s identity with the correct treatment or service is a critical factor of patient safety. The most common “wrong patient” treatment error many people may first think of is that of a …
Do clinicians need to obtain diagnostic certainty before initiating treatment?
Sep 06, 2003 · Health professionals are increasingly encouraged to involve patients in treatment decisions, recognising patients as experts with a unique knowledge of their own health and their preferences for treatments, health states, and outcomes. 1, 2 Increased patient involvement, a result of various sociopolitical changes, w1 is an important part of ...
What information should be used to identify a patient?
during the initial patient encounter. The physician order is a good source of information on determining special needs such as a private room, specific bed type, or other clinical indications, but patient access staff must also be aware of other special needs and the requirements associated with those needs.
Why do doctors see patients for the first time?
Start studying Ch. 1 Preparing for the Patient Encounter. Learn vocabulary, terms, and more with flashcards, games, and other study tools. ... - Identify patient's baseline condition and need for treatment the physician has ordered. Steps of treatment and monitoring stage - After initial assessment, administer treatment - Monitor patient's ...
Why do patients need to be given technical information that is clear and unbiased?
Patients must be given technical information that is clear and unbiased to ensure that their preferences are based on fact and not misconception.
Why do doctors need to understand patients' preferences?
To improve the quality of care they provide , doctors should understand their patients' preferences. However, this raises many challenges for doctors. Practical concerns include time pressures and difficulties in eliciting preferences from patients who may be hesitant to make treatment decisions. These are compounded by a deficit of appropriate information to support patients' decisions. Doctors may not have the appropriate interpersonal skills, particularly for communicating risk. Medical uncertainty, deficiencies in individual doctors' knowledge, and the highly variable ability of patients to understand and remember clinical information mean that risk communication is often inadequate to support patients in making informed decisions.
Why is it important for health professionals to involve patients in treatment decisions?
Health professionals are increasingly encouraged to involve patients in treatment decisions, recognising patients as experts with a unique knowledge of their own health and their preferences for treatments, health states, and outcomes.1,2Increased patient involvement, a result of various sociopolitical changes,w1is an important part of quality improvement since it has been associated with improved health outcomes3w1-w9and enables doctors to be more accountable to the public.
What is the Foundation for Informed Medical Decision Making?
Foundation for Informed Medical Decision Making (www.fimdm.org/). US group that, as a result of concerns about variations in medical intervention rates, encourages patients to play a greater role in choosing treatments. Produces web based and video decision aids
What is individualised risk information?
Individualised risk information—that is, based on each patient's clinical characteristics—is available for only a few conditions, such as the Framingham equation for stroke or cardiovascular disease.w21Even this information is probabilistic in nature and requires skilful communication.
What are the two components of treatment decisions?
Although some patients may not wish to make the final choice of treatment, many would prefer more information.w12-w14Deber suggested there may be two components of treatment decisions—problem solving (“identifying the one right answer”) and decision making (“selecting the most desired bundle of outcomes”) —and hypothesised that, whereas patients may prefer doctors to perform the problem solving component (which requires clinical expertise), patients would want to be involved in decision making.13This was supported in a survey of patients undergoing angiography.w15
What are practical concerns?
Practical concerns include the extra time needed and the difficulties in eliciting patients' preferences, exacerbated by limited appropriate information to support patient involvement
What are the four types of information gathering activities in the diagnostic process?
The committee identified four types of information-gathering activities in the diagnostic process: taking a clinical history and interview; performing a physical exam; obtaining diagnostic testing; and sending a patient for referrals or consultations.
Why is information gathering important in the diagnostic process?
It is important to note that clinicians do not need to obtain diagnostic certainty prior to initiating treatment; the goal of information gathering in the diagnostic process is to reduce diagnostic uncertainty enough to make optimal decisions for subsequent care (Kassirer, 1989; see section on diagnostic uncertainty). In addition, the provision of treatment can also inform and refine a working diagnosis, which is indicated by the feedback loop from treatment into the information-gathering step of the diagnostic process. This also illustrates the need for clinicians to diagnose health problems that may arise during treatment.
What is the importance of clinical history?
Acquiring a clinical history and interviewing a patient provides important information for determining a diagnosis and also establishes a solid foundation for the relationship between a clinician and the patient. A common maxim in medicine attributed to William Osler is: “Just listen to your patient, he is telling you the diagnosis” (Gandhi, 2000, p. 1087). An appointment begins with an interview of the patient, when a clinician compiles a patient's medical history or verifies that the details of the patient's history already contained in the patient's medical record are accurate. A patient's clinical history includes documentation of the current concern, past medical history, family history, social history, and other relevant information, such as current medications (prescription and over-the-counter) and dietary supplements.
What is a working diagnosis?
The working diagnosis may be either a list of potential diagnoses (a differential diagnosis) or a single potential diagnosis. Typically, clinicians will consider more than one diagnostic hypothesis or possibility as an explanation of the patient's symptoms and will refine this list as further information is obtained in the diagnostic process. The working diagnosis should be shared with the patient, including an explanation of the degree of uncertainty associated with a working diagnosis. Each time there is a revision to the working diagnosis, this information should be communicated to the patient. As the diagnostic process proceeds, a fairly broad list of potential diagnoses may be narrowed into fewer potential options, a process referred to as diagnostic modification and refinement (Kassirer et al., 2010). As the list becomes narrowed to one or two possibilities, diagnostic refinement of the working diagnosis becomes diagnostic verification, in which the lead diagnosis is checked for its adequacy in explaining the signs and symptoms, its coherency with the patient's context (physiology, risk factors), and whether a single diagnosis is appropriate. When considering invasive or risky diagnostic testing or treatment options, the diagnostic verification step is particularly important so that a patient is not exposed to these risks without a reasonable chance that the testing or treatment options will be informative and will likely improve patient outcomes.
What is the purpose of a clinical history interview?
Performing a clinical history and interview, conducting a physical exam, performing diagnostic testing, and referring or consulting with other clinicians are all ways of accumulating information that may be relevant to understanding a patient's health problem.
How to obtain a clinical history?
The National Institute on Aging, in guidance for conducting a clinical history and interview, suggests that clinicians should avoid interrupting, demonstrate empathy, and establish a rapport with patients (NIA, 2008). Clinicians need to know when to ask more detailed questions and how to create a safe environment for patients to share sensitive information about their health and symptoms. Obtaining a history can be challenging in some cases: For example, in working with older adults with memory loss, with children, or with individuals whose health problems limit communication or reliable self-reporting. In these cases it may be necessary to include family members or caregivers in the history-taking process. The time pressures often involved in clinical appointments also contribute to challenges in the clinical history and interview. Limited time for clinical visits, partially attributed to payment policies (see Chapter 7), may lead to an incomplete picture of a patient's relevant history and current signs and symptoms.
What is NCBI bookshelf?
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
What is a patient identifier?
The glossary of the accreditation manual defines a patient identifier as "Information directly associated with an individual that reliably identifies the individual as the person for whom the service or treatment is intended. Acceptable identifiers may be the individual's name, an assigned identification number, telephone number, ...
What are acceptable identifiers?
Acceptable identifiers may be the individual's name, an assigned identification number, telephone number, or other person-specific identifier.". Use of a room number would NOT be considered an example of a unique patient identifier. Additional examples of identifiers may include, but not limited to:
Can temporary names be used for identification?
Use of temporary names. Under some circumstances, a patient’s identity may not be able to be verified and a temporary means of identification must be used. An example of such circumstances may include an injured, unresponsive patient presenting to the emergency department.
Do you need armbands for the Joint Commission?
The Joint Commission does not require the use of arm bands. However, when armbands are used as a means of conveying patient/resident identification information, the band must be attached to the patient/resident at all times. Simply placing it on the bedside table or taping it to the bed would not be acceptable.
Is standardization of identifiers beneficial?
While standardization of the identifiers used is beneficial, there are settings and situations when variations may need to be employed. For example, in an outpatient setting where ID bands may not be used as an information source, an infant or toddler, an unresponsive patient, etc. The organization determines how accurate patient identification will be completed in these types of situations. The two patient identifiers should be consistent within each setting, not just whatever the individual practitioner or staff person wishes to use