medical chart.

User Generated

wuneevfba1

Computer Science

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

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Medical Chart
Name
Date

Nick Morris

Age

17

Gender

M

____09/12/18___________

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 one prior admission to a medical ward two years ago. The admission was for two
weeks whereby the patient was treated for severe ulcers. The patient has no history of blood
transfusion or any bleeding disorder.

Habits (tobacco, alcohol)
The patient has a positive history of alcohol use. He mostly takes wines and spirits on an occasional
basis. His weekly consumption is averagely 30 units of alcohol. Additionally, the patient has been
smoking cigarettes since the age of 16 years. He smokes two sticks per day.

Family history
The patient is the first born in a fa...


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