Assessment of Patients I
1. Question:--Ask Patient Answer:
Describe your involvement in planning your Patient should describe that the plan of care
care. was discussed with them; that they are
working to improve health status by..., etc.
2. Question: Answer:
What is your discipline's scope of assessment? Staff should verbalize what assessments they
Is it defined in writing? perform and locate a policy that reflects this.
Social Services
3. Question: Answer:
When do you request a social service/case Refer to Hospital Social Service Policy 5.38.
management consult on patients? All patients are screened for Social Service
Risk factors (discharge planning,
abuse/neglect, etc.) within 8 hours of admit.
Those meeting high-risk criteria are referred
to social services for a more in-depth
assessment. These patients receive in-depth
social services assessment within 48 hours
of admit, if deemed necessary by the
administrative house manager. An
administrative house manager is available
for emergency consults after hours,
weekends & holidays.
4. Question: Answer:
What are high-risk criteria that would indicate Education related to speech language
a referral to Speech-Language Pathology is disorder
required? Swallowing evaluation (Bedside and
Videoflouroscopy)
Head and neck cancer preoperative
counseling.
Voice restoration following total
laryngectomy
Fitting voice prostheses
Stroke evaluation/rehabilitation
Traumatic brain injury / Closed head injury
evaluation /Rehabilitation
Other concerns within the scope of practice of
Speech-Language Pathology
The physician must order the consult.
Refer to Hospital Speech-Language Pathology
Services Policy 5.36.
5. Question: Answer:
What are high-risk criteria that would indicate Decreased hearing
a referral to Audiology Services is required? Decreased speech understanding
Failed hearing screening
Tinnitus
MD must order consult. Refer to Hospital
Audiology Services Policy 5.28.
6. Question: Answer:
a) Which waived/point of care tests do you a) Answer may include urine ketodiastix,
perform on this unit? urine ketostix, urine dipstick, blood glucose,
clinitest, fecal hemoccults, gastric ph,
gastroccults, Strep A screens, or urine
pregnancy tests. Other point of care tests
b) How were you trained/retrained to perform may include hemachron (ACT) or I-stat.
these tests? b) Oriented and annual reassessment of
competence.
c) Where are policies/procedures located?
c) Polices/procedures should be available for
d) Explain the quality control you perform for all tests performed.
each test. Show me your quality control
logs.
d) Staff should explain quality control and
show logs. I-stat, ACT and blood glucose
do not have manual logs the logs are
automated and maintained in the Point of
Care Office.
7. Question: Answer:
How would you identify possible victims of -Discrepancies between history and/or
abuse/neglect? injury
-Physical Abuse
-Inconsistencies in the history in
conjunction with the criteria listed
-unusual or unexplained bruising
-head injuries, especially in infants
-retinal hemorrhages infants/children
-fractures
-burns
-repeated injuries
-Sexual Abuse
-genital injuries
-unexplained loss of developmental
milestones
-repeated UTI unrelated to other causes
-depression
-STD's in child
-pregnancy in the very young
-sexual knowledge that exceeds the level
of
maturity
-Neglect
-poor hygiene and/or lack of appropriate
clothing
-lack of heat/running water
-undernourished
-malnourished/dehydrated
-over/under medicated
-lack of immunization
-failure to thrive
-lack of medical care
-Emotional
-withdrawn
-suicidal
-excessively aggressive
-conduct disorder
-inappropriate parent/child interaction
-depression
-Domestic violence - Refer to criteria
listed above as appropriate to the
situation.
Refer to Hospital Abuse/Neglect Policy
5.5
8. Question: Answer:
What should you do if you suspect Document findings. Notify MD. Report as
abuse/neglect? mandated by law to appropriate authorities
and LSUHSC Social Service Department.
Refer to Hospital Abuse/Neglect Policy 5.5.
9. Question: Answer:
What would you do if you identified a patient Document findings. Notify MD and Case
with possible drug/alcohol dependence? Management. Case Management will
inform patient of local agencies/treatment
programs and assist patients to contact
agencies if they so desire. Refer to Hospital
Substance Abuse Policy 5.29. Note:
LSUHSC has no identified treatment
program for substance abuse.
10. Question: Answer:
What would you base the scope of intensity of The patient's condition/diagnosis, the care
further assessment on? setting, the patient's desire for care, the
patient's response to previous care, and the
patient's consent for treatment.
11. Question: Answer:
a) What special assessments and interventions a) Social, spiritual, and cultural factors that
are made for terminal patients? influence the perceptions and expressions of
grief by the patient, family, and significant
others. To the extent possible, as
appropriate to the patient's and family's
needs and the hospital's services,
interventions address: patient and family
comfort, dignity, and psychosocial,
b) Who would you consult if needs were emotional, and spiritual needs about death
identified? and grief.
b) Pastoral Services or Social Services, Case
Manager, Pain Services, or others as needed.
12. Question: Answer:
What special assessments are required prior to -assessment of mental status
moderate (conscious) sedation? -examination specific to the procedure and
any co-morbid conditions
-examination of the heart and lungs by
auscultation
-airway evaluation
-allergies
-family history of anesthesia/sedation
problems
-medication history
-abnormal lab results
-pain level and assessment
-evaluation of blood/blood component
requirements, as applicable
Refer to Medical Records
Content/Documentation Policy #6.5. and
Moderate (Conscious) Sedation Policy
5.26.
Advanced Practice RN/Physician Assistant
13. Question: Answer:
What is your discipline's scope The assessment includes, but is not limited to,
of assessment? performing an initial/ongoing patient
assessment to determine need for medical
attention, obtaining patient histories,
performing exams and requesting and
interpreting laboratory/diagnostic studies.
In addition, the Advanced Practice
RN/Physician Assistant identifies normal
and abnormal findings, monitors the
effectiveness of therapeutic interventions,
and takes actions within their scope of
practice.
Refer to Hospital Patient Assessment Policy
5.9.
14. Question: Answer:
What is the role of the staff physician in A duly licensed and credentialed staff
patient assessment? physician will either perform or supervise
the performance of a patient assessment as
outlined in the Medical Staff Bylaws, Rules
and Regulation Section on Health
Information Management and the Hospital
Patient Assessment Policy #5.9.
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