Informed Consent

Information provided in the consent

• Benefits of therapy
• The alternatives
• Anticipated time frames
• Cost
• Risks
• Consequence-personally liable if the patient not informed
Informed Consent must be:
• Comprehensible
• Or provide translator
• If patient not on legal age or mentally confused secure consent from:
a. Legally qualified surrogate
b. Parent
c. Guardian
d. Family member or
e. Court-appointed advocate
Principles of Documentation
Elements of Documentation
• Initial examination
• Evaluation
• Visit/encounter
• Reexamination
• Discharge
• Discontinuation
Other areas of consideration
1. Patient primary and treatment diagnosis
2. Physician’s orders
3. Patient barriers to treatment and their resolution
4. Patient’s consent to treatment
5. POC (goals, interventions, proposed frequency and duration, and discharge)
6. STG and LTG
7. Risk and benefit of treatment
Problem Oriented Medical Record (POMR) on
SOAP format
4Phases
1. Formation of a databases (current and past information about
patient)
2. Development of specific, current problem list
3. Identification of specific treatment plan
4. Assessment of treatment plan effectiveness
Rationale for Documentation
• To assess patient improvement Quality of Life
• For reimbursement
• For referrals
Principles of Patient
Management
Differential Diagnosis
• When patient symptoms are associated with two or more illnesses
• A systematic process to compare and contrast the symptoms to
distinguish one illness or condition from the other.
• Accurate diagnosis is the basis for better treatment decisions, plans,
and outcomes and reduction of medical errors, and limits the
possibility of inappropriate treatment.
Components of DDx
• 1. Observation and interviews
• 2. Specific tests and measures
Components: Patient Medical History
1. Primary complaint
2. Current illness
3. Previous Medical History
4. Previous Surgical History
5. Current Medications
6. Family History
7. Social History
8. Review of body systems
Importance of EBP
• Helps determine the effectiveness of the caregiver’s interventions or
outcome measures.
Principles of patient examination and
evaluation
• Examine and evaluate/ reexamine and reevaluate frequently
• Establish baseline
• Provide data and information to develop clinical diagnosis and
prognosis
• Measure the patient’s attainment of goals or functional outcomes
• Provide data and information for use by other persons
Guidelines for Patient Examination
• Gather subjective and objective information and data
• Observe the patient
• Palpate patient areas
• Test and measures
• Cardiovascular /pulmonary functions
• Functional abilities and performance and daily tasks
• Mental and cognitive function
• Review other reports and tests when available
Communication
• Primary function of life
• Verbal communication and NVC
Forms of NVC
1. Appearance
2. Body movements
3. Body positions
4. Facial expressions
5. Pantomime
6. Posture
7. Spontaneous response to stress
8. Touch
Barriers to effective communication
• Distance
• Noise and environmental confusion
• Inability to comprehend of the receiver
• Inability interpret and understand technical, medical, professional
terms, language and abbreviations
• Inadequate amount of feedback
• Complex messages
• Cultural, gender, age difference
• Illegible writings
Safety Considerations
• Hospital Codes
• Code red-fire
• Code blue-heart or respiratory arrest
• Code orange-hazardous material spill
• Code gray-combative person
• Code silver-person with weapon
• Amber alert-infant and child abduction
• External triage-external disaster
• Internal triage-internal emergency
• Code name clear-to clear all code
Medical errors
• Patient safety primary goal and focus of each person, facility, and
service area involved with patient care.
• Type of errors
1. Sentinel
2. Potential adverse
3. Active
4. Latent
Patient rights
• Right patient
• Right drug
• Right time
• Right route
• Right dose