Lesson 3 Flashcards
a contract wherein the pt voluntarily gives permission to someone (imaging staff) to perform a procedure or service.
CONSENT-
• The medical aspect of consent hopes to establish rapport with the patient through communication to secure a successful outcomes.
CONSENT-
often signed when the patient enters the hospital.
BLANKET CONSENT FORM
obtaining a patient’s permission to perform a procedure without knowledge of that procedure.
Simple consent
occurs when the patient does not stop the procedure from taking place. However, legally, silence is not an agreement.
Express Consent
occurs in emergency situations when it is not possible to obtain a consent from the patient, his or her parents, or a legal representative.
Implied consent
“ignorant consent”. This occurs when the patient has not be been informed adequately to make a responsible decision.
Inadequate consent
Legal definition: individual who is NOT autonomous and cannot give or withhold consent (eg: individuals who are menitally retarded, mentally ill, or comatose)
INCOMPETENT PATIENT
involves the collection of accurate objective and subjective data.
Good history taking
are perceptible to the senses, such as signs that can be seen, heard, or felt and such things as laboratory reports.
OBJECTIVE DATA
DATA pertain to or are perceived by the affected individual only. They include factors that involve the patient’s emotions and experiences, such as pain and its severity, and are not perceptible to the senses.
SUBJECTIVE DATA
Effective histories result 6
Open- ended questions
Facilitation
Silence
Probing (inquiring) questions
Repetition
Summarization
(nondirected, nonleading) let the patients tell the story.
Open- ended questions
(nod or say yes, okay, go on…) encourages elaboration.
Facilitation
(to give the patient time to remember) facilitates accuracy and elaboration.
Silence
(to focus the interview) provide more detail.
Probing (inquiring) questions
(rewording) clarifies information.
Repetition
(considering) verifies accuracy.
Summarization
SACRED SEVEN
Localization
• Chronology
• Quality
• Severity
• Onset
• Aggravating or alleviating factors
• Associated manifestations
is defining as exact and precise an area as possible for the patient’s complaint.
Localization
is the time element of the history.
chronology
describes the character of the symptoms.
quality
of a conditionidescribes the intensity, the quantity, or the extensive of the problem.
severity
of the complaint involves the patients explaining what he or she was doing when the illness or condition began.
onset