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Patient Evaluation

Reviewing Patient Chart/ Patient Chart Review

QuestionAnswer
Admission Notes: * Admitting diagnosis * History of present illness * Chief Complaint * Past Medical History
Patient Chart Review Signs and Symptoms: Signs Signs are objective information, those things that you can see or measure. * Color * Pulse * Edema * Blood Pressure etc.
Patient Chart Review Signs and Symptoms: Symptoms Symptoms are subjective information, those things that the patient must tell you. * dyspnea * pain * nausea muscle weakness
Patient Chart Review Occupation or employment History
Patient Chart Review Allergies or allergic reactions
Patient Chart Review Prior surgery illness or injury
Patient Chart Review Vital Signs respiration pulse blood pressure temperature
Patient Chart Review Physical Examination of the chest inspection palpation percussion auscultation
Patient Chart Review Smoking History (Formula) Smoking History Pack Years= # of packs/day X # of years smoked
Patient Chart Review Advance Directives Defined A set of instructions documenting what treatment a patient would want if he/she was unable to make medical decisions.
Patient Chart Review Advance Directives Procedure Documents should be dated signed witnessed and notarized. Copies should be given to physician and next to kin.
Patient Chart Review Advance Directives/Changes Changes can be made by the patient at any time. This is placed in the patients chart.
Patient Chart Review Types of Advance Directives * Do not resuscitate (DNR) * Living Will * Durable Power of Attorney
Patient Chart Review (DNR) a) Request not to have cardiopulmonary resuscitation performed. b) DNR orders are acceptable in all states.
Patient Chart Review Living Will a) Describes what treatments patient would want if he become terminally ill. (less than 6 months to live b) Does not allow patient to appoint someone else to make medical decisions.
Patient Chart Review Durable Power of Attorney a) Legal documents that names an healthcare proxy (agent, person) responsible for making healthcare decisions for the patient b) takes effect only when patient id unable to make decision for themselves
Patient Chart Review Respiratory Care Orders * Type of treatment * Frequency * Medical Dosage * Physicians signature
Patient Chart Review Patient Progress Notes: Respiratory Notes record date, time and reactions
Patient Chart Review Patient Progress Notes: Nursing Notes check patient status
Patient Chart Review Patient Progress Notes: Admission Notes recording pertinent patient data: name, address, date of birth, admitting physician and diagnosis
Patient Chart Review Patient Progress Notes: Maternal History check maternal and neonatal history if applicable.
Patient Chart Review Patient Laboratory * Arterial Blood Gas * Pulmonary Function Test * Imaging Reports ( X-Ray, CT, MRI, PET) * Basic Lab assessments
Patient Chart Review Intake Output: Normal Normal Urine Output is 40mL/hr approximately 1 L per day
Patient Chart Review Intake Output: Sensible Sensible water loss urine, vomiting
Patient Chart Review Intake Output: Insensible lungs and skin
Patient Chart Review Intake Output: Exceeds If Intake exceeds output results: Weight gain Electrolyte Imbalance Increased Hemodynamic Pressure Decreased Lung Compliance
Patient Chart Review Fluid Balance Change Increased CVP Greater than 6 Hypervolemia
Patient Chart Review Fluid Balance Change decreased CVP Less than 2 hypovolemia
Created by: sukar