The Health Care Process: April T. Cajandig

THE HEALTH CARE
PROCESS
April T. Cajandig
Clinical Coordinator - Midwifery
THE HEALTH CARE PROCESS
 An organizational framework for the
practice of midwifery in the Philippines and
global.
 Orderly, systematic manner of looking into
the problem presented by the patient
 Central to midwifery practice in providing
care girl clients, women and their families.
 The foundation, essential, enduring skill of
a midwife
DEFINITION
 An organized sequence of problem-

solving steps used to identify and to
manage the health problems of
clients.
STEPS of The Health Care Process
A - ssessment
P – roblem Identification
P - lanning
I - mplementation
E- valuation
Benefits of using the HCP
 Continuity of care
 Prevention of duplication
 Individualized care
 Standards of care
 Increased client participation
 Collaboration of care
Assessment
It is both the initial step and an
ongoing component in every other
step in the process.
It is also both the most basic and
the most complex skill.
The beginning point of
intervention.
Components of Assessment
A. Data Collection
B. Data Verification
C. Data Organization
D. Data Interpretation
E. Data Documentation
Data Collection
Physical Laboratory
Obsevation Interview Examination Examination
Sources of Data
A. Primary Sources
 Client is the major provider of information.
B. Secondary Sources
 Family
 Medical records
 Related literature
 Relatives and friends
 Laboratory results
 Healthcare providers
TYPES OF DATA TO COLLECT
Subjective
 those problems verbalized by the
patient. These are statements,
feelings, perceptions, or concerns
communicated by a client.
Subjective data - information that only
the client feels and can describe
(Symptoms).
DOCUMENTATION (TO RECORD
SUBJECTIVE DATA)
• Avoid generalizations – be specific.

• Don’t make summative statements –
describe.
e.g. “I’m worried about my baby’s condition”

“I don’t have enough breastmilk”
“I am giving my child a glass of milk every
morning
Objective data
 are pertinent information based on
observation or through the use of five
senses supportive to the statement of
the patient.
Objective data- can be observed,
measured, or felt by someone other
than the person experiencing them.
(Signs)
Example:
1. 250cc dark amber urine
2. 8x 16 size Abdominal binder
3. Breastmilk leaking on the left
breast
4. Pus on the umbilical cord
5. Febrile; temp. 38.9°C
Judgment or Conclusion
 based on assumptions of the
midwife and is not measurable.
PRACTICE TEST
Consider the following pieces of data and label
them
O – Objective
S – Subjective
J – Judgment or Conclusion
1. Diaper pad soaked with blood

2. Patient is afraid of cesarean delivery
because her mother died in the hospital last
week.
3. Large amount of bright red drainage from
cesarean incision site
4. Increased heart rate: 102 bpm
6. Respiratory rate of 36 cpm after
walking length of hall unassisted
7. Child’s oral intake is in excess of body
requirements
8. An intelligent and articulate 20 year-
old midwifery student
9. “I don’t want my child to be
vaccinated”
10. Breast tenderness
THE INTERVIEW:
• Midwife collects background info from
previous charts
• Ensure environment is conducive
• Arrange seats
• Allow adequate time
• Introduces self
• Identifies purpose of interview
• Ensure confidentiality of information
• Provide for patient needs before starting
Data Verification
 a process in which data are
validated as being complete and
accurate
Data Organization
 organize complete data and
information for prioritizing
strength and weaknesses.
Data Interpretation
 Necessary for identification of the
problem. It determines meaning
and significance
PROBLEM IDENTIFICATION
 Identify potential problems and

strengths.
 Write statement of problem or
strength
Planning and Outcome
Identification
Outcome Identification
 It is where the health worker and the
patient set priorities among the
identified problems and establish
outcomes showing reduction,
prevention, or elimination of the
problem.
Activities:
a. Setting priorities
b. Establishing outcomes
Guidelines for Setting Priorities
a. Maslow’s Hierarchy of Needs
b. Problems the patient feels most
important.
c. Consider patient’s culture, values,
and beliefs.
d. Consider the effect of potential
problems.
e. Safety issues.
.
f Consider costs, resources available,
personnel, and time needed to plan for and
treat each of the patient’s identified
problems.
g. Consider laws, hospital policy
statements, and outcome criteria
established for the particular setting.
h. It must be SMARTER (specific,
measurable, attainable, realistic, time-
bound, enjoyable, and rewarding
Components of Outcomes
Subject: who is the person expected to achieve
the outcome?
Verb: what actions must the person take to
achieve the outcome?
Condition: under what circumstances is the
person to perform the actions?
Performance criteria: how well is the person to
perform the actions?
Target time: by when is the person expected to
be able to perform the actions?
Measurable Verbs
Identify Describe Perform

State List Verbalize
Demonstrate Share Express
Exercise Communicate Stand
Cough Walk Relate
Hold Sit Discuss
Reestablish
Use of Time Frame
1. within 48 hours
2. by third post-operative day
3. within 45 minutes
4. in 24 hours
5. within 3 weeks of medication
therapy

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THE HEALTH CARE

 An organized sequence of problem-

• Avoid generalizations – be specific.

e.g. “I’m worried about my baby’s condition”

1. Diaper pad soaked with blood

 Identify potential problems and

Identify Describe Perform

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