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MODULE 1.0 PATIENT DATA EVALUATION

General Objective:

Upon completion of the module, the student will demonstrate an ability to review data in the patient record as integral part of the overall patient assessment.

Specific Objectives:

1.0Collect, evaluate and discuss pertinent clinical information derived from the patient’s medical record:

1.1

Patient history e.g.,

Present illness

Progress notes

Admission notes

Diagnoses

Respiratory care orders

DNR status

Medication history

Patient education (previous)

1.2Physical examination relative to the cardiopulmonary system e.g., vitalsigns, physical findings

1.3

Laboratory data e.g.,

CBC

Culture and sensitivities

Electrolytes

Sputum Gram stain

Coagulation studies

1.4Pulmonary function results

1.5Blood gas results

1.6Imaging studies e.g., Radiograph, CT, MRI

1.7Monitoring data, e.g., Pulse oximetry, ECG

1.8Sleep study results e.g., diagnosis, treatment

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