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    83 views16 pages

    Student Work Vital Signs Ahm-11-Med Office Asst

    Uploaded by

    api-688305379

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 16
    Medical Records ‘Skills Checklist Unit 4: Vital Signs and Body Measurements Name: Class: Date: ViTaL SIGN FLow CHART SIGNATURE: 1:5 | & eel KX HealthCenter2] —____—_——— Copyright© 2016 Applied Educational Systems Medical Records Unit Name: Bopy MEASUREMENT Class: Shits Checitist Vital Signs and Body Measurements Procedure Checklist |. Got apariner os dtected by your teacher. 2 Gat he folowing tems -Bolance beam seae with height bor Paper towels Note paper and pen Far: Vital Sign Flow Cheat 3. Cleanse yourhands, 4. Pula paper towel onthe scale pl | 5. Prepare the seat, | + Move both the s0-pound weight and the “pound weight fo the left side ofthe scato, hich tha zero postion, ‘+ Moke sua that he botence bar moves freely between the upper ‘ond lower quides. the Bar moves feel, then the sol . a Balanced. the bor does not move freely iti nal blanc. { + Ifthe scales not balanced, ure the seale manufacturer's | Instructions te balance i 6 Introduce youre identiy the patient, and explain the procedure, ° Fy 7. Ask the pation o lake off shoes. jackets purses, wollel, and any ‘ther heavy items. Atow eldery patents dnd hose with imited movement io keep shoe! on. 2 2 8. Help ine patient slep onfo the scole platform: The patent should sland ‘weight othe ight un tha balance bor swings between the upper nd lower guides. fon the Cente af he platform with feet apart, = 9. Release the patient. bt remain close in caze the patient needs ‘assstance. Be sure that you ore not assisting the patient when b o recording the weight measurement 10.Side the $0-pounc weight fo the ight unl fhe balance bar fal To the lower gui. Move the weight fhe el one nach side he peur | 5 ‘Add the So-pound weight fotal and the & pound! weight folalTo get the patient's body weight measurement 2.Recheck he reading and then record the body weight on note paper. 13:Help the patient step off he scale platform, Le o| k{ HealthCenter21 Copyright © 2016 Apps Eaucatona Systems Medical Records ‘Skills Checkist Unit 1: Vital Signs and Body Measurements Name: Class: Date: Bopy MEASUREMENT SEER Procedure Checklist pass | REPEAT |V4.Roise the height bar so that itis higher than the patient. isan aca! |5.Help the patient step onto the scale platform again. This time the a ie patient's back should be towards the balance beam and height bar. 16.Tellthe patent to stand up straight o a '7-Sowly lower the height bor unt stress on he op ae patons | —O - 18.Read the height measurement in inches orin centimeters. Ls a 19.Recheck the reading ond then record the height on note paper Y a 0.Help the patient step off the scale platform. ~ a 21.Throw the paper towel in a trash can, No 9° ‘22.Move the §0-pound and Yepoundl welahts back to the lel. ar 2610 2 ie postion and iower the height ber, 13.|f meosuring in inches, convert inches to feet ond Inches by dividing eS inches by 12 ? 24,Cleanse your hands Se a ‘25.Record the folowing body measurement data on the patient's chart: | * Dole . + Time o a ‘+ Body measurement data, for example Wi: 125%, Ht: ft2 Yin + Your signature ond title if working with @ pariner, switch roles and repect the procedure a = “eccording to your teacher's instructions. KX HealthCenter 2] eee Copyrieht © 2016 Apps Educational Systems Medical Records Skills Checklist Unit 2: Temperature Name: Class: Date ORAL TEMPERATURE Procedure Checklist pass | REPEAT 1. Get a partner oF drected by your leacher. Na o 2. Gel he folowing ems ecitonic thermometer -Plose sheaths Note paper “Pen _ eC Form: Vita sign low Chart | 3. Cleanse your hanes @ a 4. Put on gloves Na o 5. Inroduce youre idently the patient ond explain he procedure, 2 o 6. Pace the patient ina comfartable postion. 3 2 7. Ask he patient has haat anything to eal or eink arhas smoked in ‘he past 20 minutes. the answer "yes," wat at east 20 mites fo a a Fake the termperanue, a {3 Tum on te thermometer o a 9. Insert the thermametar probe info @ sheath orprobe cover a a To insert the covered proba under the pallens tongue ond foward side of the mouth, " 8 7 [_T Asche pation akin place whe ake waa pat 5 e Zhen the thermometer signals hal he Ternparature hos boan Taken ‘remove the probe ftom the patient's mau us 9 TSRecord ihe folowing Information on note paper + Date . + time a + Temperature |. Without touching the end ofthe sheath a probe cover, emmove om {ne thermometer and ploce iin an infectious waste container. 2 8 1S.1un of he thermometer. o D "Remove gloves and vow femawoy nie cninecton wave a = 17.Cleanse your hands o a 1Record the data on he pallens char, inclicing he folowing information: + bate + Time 7 a + Temperature + _Yoursignature ond ie ‘flfworking wih a parinr, swish oles and repeat the procedure = ‘according to yout teacher'sinsietions. el | Copyright © 2016 Apples Educational Systems KX HealthCenter2] eee Medical Records Skits Checklist Unit 2: Temperature Name: Class: Date: ‘TYMPANIC TEMPERATURE ane Procedure Checklist pass | repeat 1. Get partner os dkected by your leacher. ° 2 Gat the folowing tems + Tymponic thermometer + Probe covers + Note paper ~ ° + Pen + Form: Vil Sign Few Chart 3. Cleanse your hands 4. Put on gloves. 5. Introduce yoursel, ident the patient, and explain the proceaure. (6, Take ihe thermometer of i bare and tum ton and. needed: sel tothe proper mode. 7. Insert the thermometer probe into @ probe cover. Sal . 8, Make sue the thermemeterclsplay shows that itis ready “o afolala 2. Postion the patent in a siting postion, a 10,70 foke a temperoture inthe patient's ight ear, hold the ihermometer in yourright hand. To take o temperature inthe potentslaftear.hold | ~s {ne thermometerin yout et hand o 2a your ae hone, pul the earlobe up and back o 3 "2 Place he covered probe nto he earcandlasiorosposbie fore |. = ‘he eor conalwith he probe, |3.Holging the thermometer in ploce, press the scan or oclvate Button ‘and wal uni tna thermometer plays araacng or signal thal ites o Frshed—usualy one or hwo seconds, ‘stoke he thermometer Gut ofthe patient's ear and ead The temperature, SX HealthCenter2] eee Pogo tof Copyright © 2016 Appies Educational Systems ‘Modical Records Unit 2: Temperature Name: lass TYMPANIC TEMPERATURE ‘Skills Checktist eT Procedure Checklist 1S:Record the folowing temperature information on role paper: + Date + Time + Temperoture wih a "1" ofter the reading fo indicate a tympanic temperature reading é.Remove the probe cover and place into a waste contoiner. 17-Turn of the thermometer and relum to the bare, Ta.Remove gloves and tow them away info an ifectious waste 19.Cleonse your hands 20,Rece%d ha folowing date on the patients char + Date 1+ Temperature with a" ater the coding to incicate o tympanic tamperoure reading + Yoursignature anc ile 21.1 working with @ partner, swilch rales andl repeal ihe procedure ‘according o your teacher sinstuctons Copyright © 2018 Applied Educational Systems EL HealthCenter2] eee Pago 20f3 Medical Records ‘Stills Checklist Unit 3: Pulse Name. RADIAL PULSE Class: nEEeeeeeeeee Procedure Checklist pass | Repeat 1. Geta partner os dracted by your leacher. + Note paper + Pen No 2. Get the folowing tems + Watch or clock wih second hong he + For: Vital sign Flow Chet 3. Cleanse your hands, 4, nttoduce youre ently the potent, nd expan the procedure, | waa o 5 Place the Patient ina comtotabie postion, providing suppor under |g the erm and tuning the patents aim dowrwers. ‘6 Using the fps of your fst wo fingers, fd the patient's puke onthe thumb sie of writ. rinute. 7, When vou fades! the puke. nny ganile pressure Use thazocona | ‘hong othe watch or clock and begin counting pules for ove fal 2 a tne pute 8. While counting the pute. poy aifention To the valume and myn of paper: + Date + Time, + Pute rate ', Record the pulse date including the folowing information on nole + Pute volume (stong, weak, thread, or bounding) + Puke mhytnm (reguor or regular 10.Cleanie your hands + Dole + Time 1V-Record data on the patient's cher incliding the folowing information: + Pulte dota, for exomole P75 song and reguar + Yoursignature end tite No a 12 working with @ pesiner, swilch rales and repeat the procedure : “according fe your leachers stuns, a 0 Xi HealthCenter2] $a Paget of2 ‘Copyright © 2016 Aopled Edveatonal Systems ‘Skills Checklist Name: Class: Date: APICAL PULSE Procedure Checklist PASS | REPEAT 1, Get @ partner as dracted by you teacher Ne a 2 Gal he Faowingitors “stetnercope,- Alcohol wipes Note paper -Fen Ys 0 = Watch or clock wth second hand Ferm io Son Flow Chor Wipe ear pieces ond doptvagm of tetnorcope wih an akcohoiwipe. | Np ‘Cleanse yourhonds Iniroauce yousell identi the potent, and exnian the proved. ‘lose the door othe room or pul curt for vac Uncover te el side of he pation’ ches o ul ihe cor pieces othe siethoscope in your eam ace The X iapiregm of Ihe ssthoscope over the apex ot the pains hea e 7 wnen you ner me necrineis ue ihe secend hand of hewaieh or | = oot and beget counting heartbeats for one At cute, TO.While counting the heortbeats, pay attention fo the volume and a rhythm. a T1-Record the apical puke doia including he folowing information on ‘note paper: Dote Tre ie + PUse wole—use "AP" 10 sgnly that ts an ope ue rate afafalola a Pulse volume (song. weak, thready. or bouncing) Pulse thm regular or tregular) |2.Wipe €or pieces end claphragm of stthascope with an alcohol wipe. | a a 18.Cleane your hand Na 5 Record data on the patien?s chat inching the folowing information + ote + Time a | + Pulse data, for example AP 75 srang and regular | + Yoursignature ond tile 1sifwoking with a pariner,swfch roles and repeat the procedure ‘according to your leachersinstuctons, = 1 HealthCenter21_ Pogot of2 Copyright © 2016 Applies Educational Systems Siills Checkllet i: Respiration Name: Class: Date: RESPIRATION SaEEEEEeeeeeeeeee Procedure Checklist pass | REPEAT |, Get a pariner as drected by your feacher. pa 9 2, Get the folowing ters + Watch or clock with secon hand es + Note paper 3 o + Pen + Form: Vital sign How Chart 3. Cleanse your hands and introduce yourself fo the patient. No ° 4+ Place the tos of your st wo fingers onthe thumb side ofthe patients | —_o a ais 0 if measuring racial pub, 5. Count the numberof times the potent inhaies and exholes. Each = D ithalation and exhalation counts as one respiration. = 6. Use the second hand of ne watch or clock and count resprotion for | —_ ‘one full minute, ven 8 . 7. While counting resptation, pay dentin tothe character and hy cof the respiration 2 '8 Record the folowing respration information an nate paper + ote + Time Lo : ‘+ Respiration rote + Respiration character (normal, shalow, deep, labored, mois ee.) + Respiration myn fegular or ireguir 9, Cleanse yourhands ‘2 a TORecord the folowing data on the patents chart | + Date + Time ° o + Retokation dota or example R18 deep and reguor + Yoursignature ond tle Lf working with @ partner. switch roles and repeci the procedure

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