Medical Chart Review - Class 1 Flashcards
subjective interview could provide
basic info required for beginning to asses a pt’s condition
what do tx of hospital or nursing home in-pts provide
slightly different interview or info gathering format
review of the medical chart
review of the medical chart
provides important info
may be only source of info if the pt is unconscious, a poor historian or if there is a language barrier
what does reviewing the chart assist with
developing a safe and effective tx plan
important to be aware of this vital info before beginning tx
important info to look for in the medical chart
pt’s age
social history
admitting dx and any concurrent dx
hospital course
physicians orders
other medical problems
meds
lab values
vital signs
nursing assessment
discharge plans
social history
where the pt lives
what type of home or apartment they live in
leisure activities
use of tobacco
alc
elicit drugs
hospital course
will gather any info to reconstruct the pt’s hospital stay
hospital course should include
date of admission
any events or procedures since admission
where is info about procedures/events found
physicians report
daily notes
documentation from other members of the health care team
physicians orders
look for orders for PT
pre and post op orders
contraindications for tx
weight bearing limits
cardiac or pulmonary precautions
other medical problems
DM
heart dx
PVD
respiratory involvement
syncope
seizures
meds
what meds
when do they take them
any side effects
is the pt receiving O2 or IV fluids
lab values could include
blood gases
WBC count
hematocrit/hemoglobin levels
ECG results
pulmonary fxn tests
MRI
Xrays
etc.
lab results may
affect daily tx
lab results need to be checked
prior to every PT tx
vital signs
BP
HR
RR
what do we want to know w/ vital signs
if their BP is stable
nursing assessment includes
medical status
pain
physical status
pt orientation
medical status
what is the pt’s current status?
pain
what is the nursing assessment of pt’s pain level and pain tolerance
physical status
his the pt been out of bed at all
have they been standing or walking
how much assistance is required
pt orientation
are they oriented to time, place and person
what does a PT does with pt orientation
also evaluate it and compare to nurses assessment
d/c plans
are they any know d/c plans
is there a planned d/c date
