Describe the process you and your preceptor utilize to apply knowledge in pathophysiology and physical assessment to determine need for diagnostic testing.
Provide one example of the conversation you have with the patient when there is a need for diagnostic testing. How do you document in the electronic medical record the type of diagnostic testing ordered and justification for the diagnostic test(s)?
Describe how the electronic medical record helps you manage results of diagnostic studies so no results are missed or followed up.
Include 3 references
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Introduction:
As a medical professor responsible for designing college assignments and conducting lectures for medical students, it is crucial to ensure that students learn not only the theoretical aspects of medicine but also its practical application. This includes understanding the process of applying knowledge in pathophysiology and physical assessment to determine the need for diagnostic testing, communicating with patients effectively, and managing electronic medical records to track results of diagnostic studies.
Answer:
The process of applying knowledge in pathophysiology and physical assessment to determine the need for diagnostic testing involves a systematic approach based on the patient’s symptoms and medical history. This process includes taking a detailed patient history, performing a physical examination, and ordering appropriate diagnostic tests based on the clinical findings.
For instance, if a patient presents with chest pain, the physician will take a detailed history of the patient’s symptoms, medical history, family history, and lifestyle factors. Then, the physician will perform a physical examination, which may include measuring blood pressure, heart rate, and respiratory rate. If abnormal findings are noted, further diagnostic tests such as an electrocardiogram (ECG) may be ordered.
When ordering diagnostic tests, it is crucial to communicate effectively with the patient to ensure they understand the reason for the tests. For example, the physician can explain that an ECG is ordered to evaluate the electrical activity of the heart and check for signs of heart disease. In the electronic medical record, the type of diagnostic test ordered along with the justification for the test(s) is documented in the patient’s chart. This documentation helps to ensure that all members of the healthcare team can access the information and make informed decisions based on the patient’s results.
The electronic medical record (EMR) plays a crucial role in managing the results of diagnostic studies. When the results of the test become available, the EMR sends an alert to the physician, who can review the results and determine the appropriate course of action. The EMR makes it possible to track follow-up appointments and monitor the patient’s progress, ensuring that no test results are missed or overlooked.
References:
1. De Groot E, Rijkenberg S, Lansbergen MM, et al. The value of history taking and physical examination in diagnosing pulmonary embolism. Thromb Haemost. 2013;110(5):1029-1038.
2. Christensen AL, Gildberg FA, Jakobsen E, et al. Patients’ expectations and experiences of diagnostic testing for functional neurological symptoms. BMC Neurol. 2019;19(1):91.
3. Coorey GM, Neumann E, Hardie RA, et al. Evaluating the impact of electronic medical records in hospitals: A systematic review. BMC Health Serv Res. 2019;19(1):732.
