Module 05 Case Scenario - How to Complete a Medical Chart

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Writing

Description

The purpose of this assignment is for you to become familiar with the components of medical charts in order to understand how they are used in providing good health care.

Download and complete this Medical Chart Template for a patient who has alcohol poisoning. The patient demographics and chief complaint have been provided. Please invent the details for any components which do not require specific/accurate facts.

  1. Include all the components of a medical chart.
  2. Use accurate information for the symptoms the patient would be experiencing.
  3. Use references; remember to use APA format and cite your information.

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Medical Chart Name Date Nick Morris Age 17 Gender _______________ Chief complaint Patient is carried into the ER by several friends. They say he passed out during a party and they don’t know what’s wrong with him. They are not sure how long he has been unconscious. They were asked if he had been drinking, and they say that he has been drinking all night. One friend says he seemed confused at one point. Medical history Replace this with your text. Habits (tobacco, alcohol) Replace this with your text. Family history Replace this with your text. Surgical history Replace this with your text. M Medications Replace this with your text. Allergies Replace this with your text. Physical Exam Replace this with your text. Discussion Questions 1. How does a medical chart help diagnosis and treatment? 2. How might incomplete information on a medical chart cause a misdiagnosis of the problem or condition or delay treatment that could be life-saving? In Nick's case, his friends could provide information on what he had been doing prior to his visit to the Emergency Room. What if Nick's friends could not provide complete information? How would this affect his care?
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Explanation & Answer

Attached.

Medical Chart
Name

Nick Morris

Age

17

Gender M

Date _______________
Chief complaint
Patient is carried into the ER by several friends. They say he passed out during a party and they
don’t know what’s wrong with him. They are not sure how long he has been unconscious. They
were asked if he had been drinking, and they say that he has been drinking all night. One friend
says he seemed confused at one point.

Medical history
The patient has ever been admitted in the hospital six months ago, with some alcohol intoxication.
The examination undertaken was blood alcohol content test after physical examination suggested
alcohol use (Kraut and Kurtz, 2008). The patient was asked to quit taking alcohol and start a
medical therapy program to reduce the level of alcohol intoxication in his body. The patient did not
complete the therapy since he did not report on the third day of therapy.

Habits (tobacco, alcohol)
Beyond alcohol, the patients, is reported to have been smoking cigarettes. His poor eating habits
have made his body weak to tolerate the excessive alcohol intake. Nicks friends lik...


Anonymous
This is great! Exactly what I wanted.

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