Why does assessment accuracy and thoroughness matter? What do we use it for anyways? -
ANSWER Accuracy improves the effectiveness of the entire health care team
Assessment provides the health care team with the baseline on the patient and what is the
normal for that patient
Documentation acts as evidence for need of care, services, and referrals
What is clinical reasoning - ANSWER Based on good assessment
This is analyzing patient assessment and data
Sign - ANSWER Objective data
Symptom - ANSWER Subjective data
The sequence of assessment - ANSWER Inspection
Palpation
Percussion
Auscultation
Inspection - ANSWER Inspecting each are for size shape color or symmetry
Simply just looking
Palpation - ANSWER an examination technique in which the examiner's hands are used to feel
the texture, size, consistency, and location of certain body parts
,Touch gathers information
Percussion - ANSWER tapping on a surface to determine the difference in the density of the
underlying structure
Tap skin with fingertips to vibrate underlying tissues and organs
Auscultation - ANSWER Listening with a stethoscope
Listening to sounds within body
Why is it good to have adequate documentation of your assessment data - ANSWER
Communication with healthcare team
Care place development
Insurance audits
Legal situation
TMJ Dysfunction - ANSWER Popping, clicking of jaw when opening and closng
Epistaxis - ANSWER Nose bleed
Rhinorrhea - ANSWER nasal discharge
Anosmia - ANSWER Decrease/loss sense of smell
Consensual light reflex - ANSWER Pupil constricts in response to light directed at the other eye
, Size of a normal pupil - ANSWER 3-4 mm
Nystagmus - ANSWER Jerky/oscillating eye movement during EOM testin
Visual accommodation - ANSWER Pupillary size adjustment to items at a distance as well as
close
Ptosis - ANSWER Eye lid droop
Strabismus - ANSWER Detected using the cover-uncover test
Exopthalmus - ANSWER Protruding eyes (seeing the whites above the iris) thyroid
CN 1 - ANSWER Olfactory
Smell
Using coffee or peppermint
CN 2 - ANSWER Optic
Visual acuity
Sloan chart 20 ft away
Cn3 - ANSWER Occulomotor
Contraction and dilation
EOM and PERRLA
ANSWER Accuracy improves the effectiveness of the entire health care team
Assessment provides the health care team with the baseline on the patient and what is the
normal for that patient
Documentation acts as evidence for need of care, services, and referrals
What is clinical reasoning - ANSWER Based on good assessment
This is analyzing patient assessment and data
Sign - ANSWER Objective data
Symptom - ANSWER Subjective data
The sequence of assessment - ANSWER Inspection
Palpation
Percussion
Auscultation
Inspection - ANSWER Inspecting each are for size shape color or symmetry
Simply just looking
Palpation - ANSWER an examination technique in which the examiner's hands are used to feel
the texture, size, consistency, and location of certain body parts
,Touch gathers information
Percussion - ANSWER tapping on a surface to determine the difference in the density of the
underlying structure
Tap skin with fingertips to vibrate underlying tissues and organs
Auscultation - ANSWER Listening with a stethoscope
Listening to sounds within body
Why is it good to have adequate documentation of your assessment data - ANSWER
Communication with healthcare team
Care place development
Insurance audits
Legal situation
TMJ Dysfunction - ANSWER Popping, clicking of jaw when opening and closng
Epistaxis - ANSWER Nose bleed
Rhinorrhea - ANSWER nasal discharge
Anosmia - ANSWER Decrease/loss sense of smell
Consensual light reflex - ANSWER Pupil constricts in response to light directed at the other eye
, Size of a normal pupil - ANSWER 3-4 mm
Nystagmus - ANSWER Jerky/oscillating eye movement during EOM testin
Visual accommodation - ANSWER Pupillary size adjustment to items at a distance as well as
close
Ptosis - ANSWER Eye lid droop
Strabismus - ANSWER Detected using the cover-uncover test
Exopthalmus - ANSWER Protruding eyes (seeing the whites above the iris) thyroid
CN 1 - ANSWER Olfactory
Smell
Using coffee or peppermint
CN 2 - ANSWER Optic
Visual acuity
Sloan chart 20 ft away
Cn3 - ANSWER Occulomotor
Contraction and dilation
EOM and PERRLA
