Institute: ONC | Component: 2 | Unit: 4 | Lecture: b | Slide: 7
Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Gathering data and analyzing findings Making a diagnosis The impact of EHRs and technology on clinical decision-making
Slide content:Disease often tells its secrets in a casual parenthesis. -Wilfred Trotter Getting the story Open-ended questions Enabling the person to tell his or her story Including/excluding family, others Filling in the details Closed-ended questions Comprehensive checklists, review of systems The tools affect the process Collection Documentation 7
Slide notes:As mentioned earlier, data gathering uses a combination of open-ended and closed-ended questions. Initially, clinicians try to get the story from the patient using open-ended questions that allow the person to tell the story in his or her own words. The clinician may include or exclude family members and others as historians, depending on the patients ability to communicate, the sensitive nature of the information, and other factors. Once this initial story is told, the clinician may proceed with more closed-ended questions either to pursue specific hypotheses or to ensure that the information is complete. Clinical documents refer to this approach as a review of the patients 11 major body systems (nervous system, integumentary system, respiratory system, digestive system, excretory system, skeletal system, muscular system, circulatory system, endocrine system, reproductive system, and lymphatic or immune system). Its important to understand that the tools used to gather, record, and analyze information may affect the process of obtaining this information and that collection of information is different from documentation . Clinical information systems and EHRs can facilitate the clinicians data collection through use of prompts and questions that display according to the patients identified signs, symptoms, and diagnosis. 7