Right to thorough history and physical a quality review


Case Scenarioi: Right to Thorough History and Physical A quality review includes a review of the thoroughness of a health care professional's documentation of the patient's history and physical-from which flows the treatment plan, follow-up care, and discharge instructions. This is often due to the nature of human beings, thus the need for satisfaction surveys, peer review, performance evaluations, data collection, and so on. The beginning point of patient care involves taking a full and complete patient history and physical that involves a total systems review of the patient in order to develop a treatment plan. This activity is not an assignable activity. It is not a peer review. It is not a medical record review or chart audit. It is the physician who must conduct this review and take the necessary steps to identify the areas in need of improvement and to recommend those changes to the medical executive committee for implementation. It is a clinical review by those trained to do so. Its purpose is to remove the disparities that exist among those decision makers who are responsible for coordinating patient care.

1. Discuss the importance of thorough patient screenings and assessments.

2. Describe what virtues and values are compromised when an accurate and thorough patient screening is not conducted upon a patient's arrival in the emergency room.

3. How are a patient's rights affected when little attention is paid to the patient's complaint(s)?

4. Discuss why you believe health care professionals become complacent and do not listen well when a patient describes his or her ailment(s). Consider the hospital setting (e.g., emergency department) and the doctor's office.

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