of motivation possessed by the consumer (interviewee). Factors that enhance the quality of an interview consist of the participants knowledge of the subject under consideration, their patience, temperament, listening skills, and attention to both verbal and nonverbal cues. Courtesy, understanding, and nonjudgmental attitudes must be mutual goals of both the interviewee and the interviewer. Finally, the health care provider must be an informed and skilled practitioner to function effectively in the therapeutic communication process. This kind of provider development requires an individuals commitment to consistently seek out and participate in a variety of continuing education learning experiences related to the entire spectrum of health care services.
Although the physician determines the overall medical management of the person requiring health care services, he or she depends upon the assistance of other members of the health care team in implementing and evaluating the patients ongoing treatment. Nurses and hospital corpsmen spend more time with the hospitalized patient than all other providers. This places them in a key position as data collecting and reporting resource persons.
The systematic gathering of information is called data collection and is an essential aspect in assessing an individuals health status, identifying existing problems, and developing a combined plan of action to assist the patient in his or her health needs. The initial assessment is usually accomplished by establishing a health history. Included in this history are elements such as previous and current health problems; patterns of daily living activities, medication, and dietary requirements; and other relevant occupational, social, and psychological data. Additionally, both subjective and objective observations are included in both the initial assessment gathering interview and throughout the course of hospitalization.
Subjective observations, which include symptoms, consist of the verbal information given to the provider by the patient or a significant other person. These include such things as a description of pain or discomfort, the presence of nausea or dizziness, and a multitude of other descriptions of dysfunction, discomfort, or illness.
Objective observations, which may also include symptoms, are those that can be actually seen, heard, touched, felt, or smelled by the health care, provider. Included in objective observations are measurements such as temperature, pulse, respiration, skin color, swelling, and even the results of tests.
Intelligent assessments are the result of accurate observations that require a combination of theoretical insight and perfected skills, both of which require a constant effort towards professional development in the provider. Accurate and intelligent assessments are the basis of good patient care and are essential elements for providing a total health care service. As such, hospital corpsmen must know what to watch for and what to expect. It is important to be able to recognize even the slightest change in a patients condition, since this may indicate a definite improvement or deterioration. Health care providers must be able to recognize the desired effects of medications and treatments, as well as undesirable reactions to them. Both of these factors may influence the physicians decision to continue, modify, or discontinue parts or all of the treatment plan.
Equally as important as assessments is the reporting of these data to appropriate team members. Reporting consists of both vocal and written communications and to be effective must be done accurately, completely; and in a timely manner. Written reporting, commonly called recording, is documented in the patients record. Maintaining an accurate, descriptive clinical record serves a dual purpose. It provides a written report of the information gathered about the patient and serves as a means of communication to all those involved in the patients care. The record also serves as a valuable source of information for the development of a variety of careplanning activities. Additionally, the clinical record is a legal document and is admissible as evidence in a court of law in claims of negligence and malpractice. Finally, these record serve as an important source of material that can be used for educating and training health care personnel and for compiling research and statistical data.
It is imperative that the health care provider follows some basic guidelines when making written entries in the record. All entries must be recorded accurately and truthfully. The omission of an entry is as inaccurate as an incorrect recording. Each entry should be concise and brief; therefore, extra words and vague notations are to be avoided. Recordings must be legible; if an error is made, it must be deleted following the standard Navy policy for correcting erroneous written notations. Lastly, all health care providers