Patient care and management
Prepared by Aimen khalil
Lecturer in MIT
Patient communiation
• Communication has been defined as “the
transmission of information, thoughts, and
feelings so that they are satisfactorily received
or understood.”
• Good patient communication involves
recognizing and responding to the patient as a
whole person—an approach frequently
termed “patient-centered” care.
Importance of Good patient
communication
Patient-Doctor communication is important
– Improved satisfaction
– Improved compliance
– Improved decision making
– Better health outcomes
– Decreased malpractice claims
Communication skills
• Essential for diagnosing and treating illness
• Essential in establishing a meaningful patient-
doctor relationship
• Facilitates educating and counseling patients
Information gathered must be:
– Objective
– Accurate
– Precise
Model relationship between health care
and patient
• Trust
• Compassion
• Open and honest communication
• Respect
Medical Records
• Medical records management systems are
only as good as the ease of retrieval of the
data in the files.
• Organization and adherence to set routines
will help to ensure that medical records are
accessible when they are needed.
Important points
• Reasons for keeping accurate records
• Ownership of records
• Differences among types of records
• Differences among types of information
• Making corrections in the record
• Filing procedures and systems
• Forms found in medical records
Importance of medical records
• Assist the health care in providing the best
possible care to the patient
• Offer legal protection to those who provide
care to the patient
• Provide statistical information that is helpful
to researchers
• Vital for financial reimbursement
Ownership of medical records
• The maker, who initiated and developed the
record, owns the physical medical record.
• The maker can be a physician or a medical
facility.
• Patients have a right of access to the
information in the record.
Points to remember
• Medical records must be kept confidential and
in a secured, locked location.
• The record should never leave the medical
facility in which it originated.
Creating an Efficient Medical Record System
The system should:
• provide for easy retrieval
• be organized and orderly
• contain information that is completely legible
• contain accurate information
• show information that is easily understood
and grammatically correct
Types of medical records
• Paper-based medical records
• Computer-based medical records
Ensuring Patient Safety
in radiology
In Radiology
• Step 1
• Radiology ‘Request/Consent Form’
Clear & legible
Provision of mandatory information
Patient Details(preferably Addressograph label)
Full Name/ DOB/ MRN(medical record number)
Ward & Date Written
Procedure Requested (including side)
Relevant Clinical History
Referring Doctor Contact Details
Printed Name/ Signature/ Page No.
Incomplete/Incorrect Request Form – Immediately notify Referrer or Ward Nurse
Step 2
• General X-ray
• (General, Mobiles, Emergency - Resus, Mammography,
Screening)
• Confirm before procedure
Clinical history corresponds with Requested exam
Correct site & side(right or left) is being examined
• . Interventional (invasive) Radiology
• (All invasive procedures covering CT / Ultrasound / Angiography / Mammography and selective
Screening procedures)
• In procedure room, with patient present.
• Confirm patient ID, request/consent forms, image data all correct.
• Site marked by interventional doctor.
Step 3
• Team Time Out
• Post Procedure (all Radiology procedures)
• Ensure that:
Correct details are attached to the image/s
Patient details & side marker/annotations on post-processed image/s are
correct
Certified Time Out Verification sticker
Radiographer/s to complete checklist, procedure, date, print name &
sign
scanned to PACS(picture archieving and communication system, then
placed in patient medical notes
Getting right in Radiology
Staff related responsibilities
• Patient Transfers
• Radiology staff (Front Desk) are required to complete ALL the front
section of the Radiology Patient Transfer Slip:
• Check adequacy of Request Form (completion of mandatory
information fields). Follow Request Form Completion Policy.
• To transcribe procedure & patient details from Request Form to
Patient Transfer Slip.
• Phone Ward Nurse responsible for patient to arrange transfer stating:
• Your name and department (Radiology)
• “I have a Request Form for (Patient Name) to have an (Radiology
procedure
Patient transfer
• The following questions should then be asked:
1. What is the patient MRN?
2. Is the patient ready for their procedure?
3. Do they travel in a bed or wheelchair?
4. Do they require a Nurse Escort?
5. What bed number are they?
6. Do they have electrical equipment on the bed e.g..IMED?
(included medical imaging machine)
7. Do they need oxygen?
8. Does the Orderly need Personal Protective Equipment?
Patient transfer
• For all procedures, especially CT & Angiography
1. Has the patient consented or are they able to consent?
2. When was the last time the patient had something to
eat?
3. Does the patient have a cannula?
4. Is the patient on anticoagulation therapy?
• When all necessary information has been established,
complete front side of Radiology Patient Transfer Slip
Transfer slip
Radiology Patient Transfer Slip
Ward and Bed No. Destination General CT
Family name Screening Angio
Given name Ultrasound MRI
MRN Region
Nurse escort? Yes No Travel Chair Bed
Protective equipment? Yes No Checked by (signature)
