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Patient Evaluation
Reviewing Patient Chart/ Patient Chart Review
| Question | Answer |
|---|---|
| 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
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