Which examples are objective patient cues collected from the electronic health record

In everyday life, you and me conduct many informal assessments. One common assessment is whether you or me is hungry and when will you or me will be able to eat next. Such assessments made each day determine many of our actions and influence our comfort and success for the remainder of the day.

Virtually every health care professional performs assessments to make professional judgments related to patients. Doctors and nurses make assessments on a patient, the patient’s family, or the patient’s community to determine medical and nursing interventions that directly or indirectly influence the health status of a patient.

Pals, the purpose of a doctor or nursing health assessment is to collect subjective data -data that rely on the feelings or opinions of the person experiencing them and which cannot be readily observed by another, and objective data – which are measurable data (also called signs) that can be seen, heard, or felt by someone other than the person experiencing them, to determine a patient’s overall level of functioning in order to make a professional clinical judgment.

Subjective data from the patient’s point of view (also referred to as symptoms) are obtained through interviews with the patient, includes:

1. data regarding sensations or symptoms (e.g., pain, hunger)
2. feelings (e.g., happiness, sadness)
3. perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the patient

Objective data on the other hand, are directly observed by the examiner and those obtained by general observation and by using the four physical examination techniques: inspection, palpation, percussion, and auscultation and typically includes :

1. physical characteristics (e.g., skin color, posture)
2. body functions (e.g., heart rate, respiratory rate)
3. appearance (e.g., dress and hygiene)
4. behavior (e.g., mood, affect)
5. measurements (e.g., blood pressure, temperature, height, weight)
6. results of laboratory testing (e.g., platelet count, x-ray findings)

Doctors also base their initial assessments from the patient’s medical/health record as another source of objective data, which is the document that contains information about what other health care professionals (i.e., nurses, physical therapists, dietitians, social workers) observed about the patient. Doctors can also gather objective data made by observations noted by the family or significant others about the patient.

However, the purpose of a nursing health history and physical examination differs greatly from that of a medical or other type of health care examination (e.g., dietary assessment or examination for physical therapy). A nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the patient. Thus the nurse performs holistic data collection.

In contrast, the doctor performing a medical examination focuses primarily on the patient’s physiologic development status.

As Health Information Management (HIM) / Medical Records (MR) practitioners working at a JCI accredited hospital or a hospital being accredited, you need to know about a quality standard declared by the Joint Commission International (JCI) through the Standard AOP.1.3 which states “The patient’s medical and nursing needs are identified from the initial assessments and recorded in the clinical record.” and its five (5) Measurable Elements (MEs).

The JCI quality standard AOP.1.3 is yet another medical documentation requirement as recorded in your medical records

An initial comprehensive assessment involves a collection of subjective data about a patient’s perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the patient’s overall function) as well as objective data gathered during a step-by-step physical examination.

In a hospital setting, the doctor is responsible for the objective data collection for an initial comprehensive assessment and usually performs a total physical examination when the patient is admitted, while the nurse typically collects the subjective data, especially those related to the patientt’s overall function.

The objective data collection by the doctor identifies the patient’s medical needs from this initial assessment, documented health history, physical exam, and other assessments performed based on the patient’s identified needs as required by the JCI Standard AOP.1.3, ME 1.

The initial assessment by a nurse is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the process: diagnosis, planning, implementation, and evaluation. Although an initial assessment process precedes the other phases in the formal nursing process, nurses are always aware that assessment is ongoing and continuous throughout all the phases of the nursing process.

The nursing care needs of the patient identified by the nurse’s holistic data collection as outlined above, thus complies with the JCI Standard AOP.1.3, ME 2 i.e the nurse’s documented assessment, the medical assessment, and other assessments performed are based on the patient’s needs.

Regardless of who collects the data, a total initial health assessment (subjective and objective data regarding functional health and body systems) is needed when the patient first enters a hospital and periodically thereafter to establish baseline data against which future health status changes can be measured and compared. Frequency of comprehensive assessments depends on the patient’s age, risk factors, health status, health promotion practices, and lifestyle

The identified medical needs and the identified nursing needs of the patient must be documented in the patient’s clinical record as required by the JCI Standard AOP.1.3, ME 3 and ME4 respectively.

To accomplish the requirements of the JCI Standard AOP.1.3 namely ME 1. ME 2, ME 3 and ME4,  a hospital must determine the following requirements incorporated within written  policies and procedures which supports consistent practice in all areas :

1. the minimum content of the initial medical and nursing and other assessments
2. the time frame for completion of assessments including completion of the most urgent care needs identified from integrated assessments
3. the documentation requirements for assessments including the integration of the additional assessments by other health care practitioners, including special assessments

If the above three requirements are met, I strongly believe that a hospital complies with the JCI Standard AOP.1.3, ME 5 which states that “Policies and procedures support consistent practice in all areas”.

Although the medical and nursing assessments are primary to the initiation of care, there may be additional assessments by other health care practitioners, including special assessments and individualised assessments. This is an integration requirement of the third requirement of written  policies and procedures on initial assessments I mentioned above.

Examples are, when a physical therapist performs a musculoskeletal examination, as in the case of a stroke patient, and a dietitian who may take anthropometric measurements in addition to a subjective nutritional assessment.

These assessments must be integrated into the initial assessment and the most urgent care needs identified. This is a time frame requirement of the second requirement of written  policies and procedures on initial assessments.as I also mentioned above.

Once a patient’s medical and nursing needs are identified from the initial assessments and duly recorded in the medical record, I conclude that a hospital then complies by the JCI Standard AOP.1.3

Please take note that the JCI Standard AOP.1.3 does not include the initial medical and nursing assessments of emergency patients.

References:
Janet, W & Jane, HK 2010, Health assessment in nursing, 4th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA

Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA