Health Assessment Digital Clinical Experience™ Example Comment Bank Responses

Health Assessment Digital Clinical Experience™ Example Comment Bank Responses Top Issues: Suggested Feedback: Student is documenting subjective data in the objective data category in the Electronic Health Record, and vice versa **For Undergraduate** This only applies to Health History, Focused Exams, and Comprehensive Assessment When documenting, make sure that the appropriate information is collect and documented in the correct place. Remember that subjective data is collected from the patient as questions are posed (i.e. past medical history, history of present illness, review of symptoms etc.) Objective data is the physical exam data that is obtained from the patient through assessment exam skills i.e. lung sounds, heart sounds etc. Defining the difference between subjective and objective data Subjective: Apparent only to person affected; includes client’s perceptions, feelings, thoughts, and expectations. It cannot be directly observed and can be discovered only asking questions. Objective: Detectable by an observer or can be tested against an acceptable standard; tangible, observable facts; includes observation of client behavior, medical records, lab and diagnostic tests, data collected by physical exam. Documentation is not detailed enough: either subjective or objective Documentation with inadequate details and/or organization; inadequate identification of abnormals and pertinent normals noted; inadequate use of professional language. The model charting in the DCE is great for review about what to collect and document in an exam. Also review the model charting for documentation flow i.e. the patient interview should begin with asking the patient about their chief complaint, then moving to the HPI, then to past medical history etc. Organization/Flow of Transcript Try to start your exam with a professional introduction and questions before doing the physical assessment. And when performing your physical exam, remember to proceed in an organized manner from head to toe i.e. start with the HEENT exam and move down the body in a logical manner. This keeps a nice flow for the patient and examiner. Student did not mark assignment as “turned in” Please make sure you click to mark your best attempt as "turned in." This ensures that I know which assignment attempt you want me to grade. Problems with Patient Communication: Suggested feedback: Ask specific questions Upon review of the transcript, more attention should be made to ask the patient specific questions. Questions should be phrased without the use of pronoun and be directly asking the information you want to know. For example: No- “Can you put pressure on it?” Yes- “Can you put pressure on your foot?” Transitions Need to transition each time you are going to ask questions in a different area and assess a different area. Avoid asking compound questions. No- “Do you take drugs or alcohol?” Yes- “Do you take drugs?” “Do you drink alcohol?” Health History: Suggested feedback: Objective data in Review of Systems (ROS) The Review of Systems (ROS) is where you collect subjective data from the patient by asking them questions about each system and then they confirm or deny the symptom. There should not be any objective physical assessment data in the ROS. You have to document if they confirm or deny each symptom for each system i.e. patient denies chest pain, patient denies palpitations. Simply documenting “no” or “negative” does not indicate to the reader which factors you asked about. Thorough review of Health History (leaving parts out) T0 evaluate the past and present health state of each body system a complete ROS needs to be completed. Each system from general overall health to the respiratory system to musculoskeletal system needs to be covered. Issues with obtaining Health History data To obtain data for the health history, you must utilize good interview techniques and communications skills. Record accurately. DO NOT ASSUME. For example, the patient denies have chest pressure but do not assume that he does not have chest pain- you need to ask this question specifically.