sick call screener course patient presentation call screener's...physical examination •report...
TRANSCRIPT
![Page 1: Sick Call Screener Course Patient Presentation Call Screener's...Physical Examination •Report your findings by system from head to toe in a sequential order ... physical examination](https://reader034.vdocuments.mx/reader034/viewer/2022042109/5e8942a147b90e6352331c04/html5/thumbnails/1.jpg)
R3
Relevant, Responsive, Requested
1.4-2-1
Sick Call ScreenerCourse
Patient Presentation(1.4)
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R3
Relevant, Responsive, Requested
1.4-2-2
Enabling Objective
• Perform a patient presentation
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R3
Relevant, Responsive, Requested
1.4-2-3
Introduction
• The presentation is passing the pertinent history and findings from the Corpsman to the provider
• Use effective communication
• Assists with providing continuity of careand ensuring patient safety
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R3
Relevant, Responsive, Requested
1.4-2-4
Presenting a Patient
• Rapport– Introduce yourself if it is the first time working
with your provider
• General information– Rank / Title
– Name
– Age
– Gender
(U.S. Navy photo Released)
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R3
Relevant, Responsive, Requested
1.4-2-5
History of Present Illness
• Report the chief complaint
• Pertinent information from the HPI using OLDCARTS– Onset
– Location
– Duration
– Characteristics
– Aggravating factors
– Relieving factors
– Temporal factors
– Severity
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R3
Relevant, Responsive, Requested
1.4-2-6
Supporting History
• Discuss any pertinent interval history from:
–Past medical history
–Surgical history
–Family history
–Social history
(U.S. Navy photo Released)
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R3
Relevant, Responsive, Requested
1.4-2-7
Review of Systems
• Report all positive and negatives from the review of systems
• Report all positive and negatives from the constitutional symptoms
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R3
Relevant, Responsive, Requested
1.4-2-8
Objective• Report your positive and negative
findings from your physical examination of the patient.
– General impression
– Physical Examination - By systems and usually from head to toe in a sequential order
– Vital signs
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R3
Relevant, Responsive, Requested
1.4-2-9
General Impression
• Report your general impression of the patient taking note of:
– Signs of distress
– Mental status
– Gross deformities
– Facial expressions
– Body language
– Gait abnormalities
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R3
Relevant, Responsive, Requested
1.4-2-10
Physical Examination
• Report your findings by system from head to toe in a sequential order
• Avoid jumping around body systems in your report
• Provide the patient’s vital signs and whether they were taken manually
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R3
Relevant, Responsive, Requested
1.4-2-11
Assessment
• Provide assessment based upon the patient’s history, your general observations and your physical examination
• Some provider may ask for possible differentials, it is wise to think of a few possibilities prior to presenting the patient
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R3
Relevant, Responsive, Requested
1.4-2-12
Plan
• The plan may include:
– Pt education and reassurance
– Medications
– Rest
– Stretches, salt water gargles, elevation, ice
– Follow up instructions
– Duty status/disposition
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R3
Relevant, Responsive, Requested
1.4-2-13
Barriers to Reporting
• Unnecessary information
• Lengthy report
• Language barriers
• Missed information
• Lack of standardization
• Interruptions
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R3
Relevant, Responsive, Requested
1.4-2-14
Summary and Review
• Perform a patient presentation
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R3
Relevant, Responsive, Requested
1.4-2-15
Questions