Description
Unformatted Attachment Preview
Charting packet #1
Instructions
1. Consider this encounter with your pt from a space of empathy and service.
2. Given the information provided, complete the following critical thinking activity:
a. Chart chief complaint – clear and concise
b. Signature and title at the right-hand margin once completed
c. If you do not know some detail, indicate what you would do in the clinic?
d. Each charting notation must be handwritten and legible. Computer generation is not
acceptable.
3. Pt Interview questions:
a. For each, write out 4-5 clarifying questions you would ask your pt to obtain data for your
provider’s evaluation
b. Think of previous coursework (Disease & Path, Micro etc.) when constructing these
questions
4. Lens work: Clinical Reasoning activity
a. Refer to the PATIENT STATUS” handout for ideas for each lens box.
b. Most of these boxes will require you to consider the holistic care of patients.
c. Sufficient responses will be more than just a couple of words. This is where you try to
figure out more pieces of the puzzle.
Patient: Leanard R. Showalter (5/5/1995)
Mr. Showalter has scheduled an appt due to sinus pain, particularly around his eyes. He is
complaining of ringing in both ears, fever, saying that his taste is getting “weird.” He is worried that it
is beginning to settle in his throat. He did run a fever last night of 101.8 degrees and took some
Tylenol – it did provide some help.
Date:
Time:
Pt Name:
D.O.B:
LMP:
Allergies
Meds: (Initial by MA/CMA/RN)
____ No Medication Changes
_____ Medication changes as follows:
Page
1
Interview Questions:
Hlth 243/F23/charting#1/ela
Due: Wed, 10/4/23 @ 0900
__________/15 points
Complete the following holistic patient care lenses:
Pathophysiology:
Psychological/Emotional Factors:
Situational Awareness:
What will your provider need you to get
ready?
_________/ 5 points
Patient: Patient: Alberta Murray (1/31/1953)
Mrs. Murray is experiencing shoulder pain today. Her husband has Alzheimer’s and is becoming
more combative. This is the same shoulder he wrenched about 3-4 months ago. Pain is 7/10 and it
is difficult to move her arm forward or raise it above her head.
Date:
Pt Name:
LMP:
Meds: (Initial by MA/CMA/RN)
Time:
D.O.B:
Allergies
____ No Medication Changes _____ Medication changes as follows:
Psychological/Emotional Factors:
Situational Awareness:
Therapeutic Communication Needs:
Page
2
Pathophysiology:
Hlth 243/F23/charting#1/ela
Due: Wed, 10/4/23 @ 0900
__________/15 points
Interview Questions:
Identify the following as either subjective or objective data: (2 points)
_____ Data that the patient describes based on experience, sensations, cultural norms, etc. and is
not measurable by the five senses
_____ Data that came be obtained through the five senses, measurable and cannot be refuted
_____ Blood pressure is 118/68
_____ Pain scale is 6/10
_____ I am having a really bad cough at night
_____ SpO2 = 97%
_____ The pain is mostly on the left side of my abdomen
_____ My sense of smell is not what it used to be
_____ CBC = wnl
_____ No BM for the past five days
_____ Blurry vision
_____ Wt: 185.4 pounds
_____ Face is flushed and sweaty
_____ UA specific gravity of 1.040
_____ Nystagmus
_____ Pruritis
_____ Peak Flow results: 1) 440 lpm, 2) 450 lpm, 3) 440 lpm
_____ Tenesmus
_____ Pulse is 88, bounding & irregular
_____ Purulent discharge noted with peripheral redness
Page
3
Identify the following medications by specific category (1 point)
1. Lipitor: _______________________________________________________
2. Lisinopril: _____________________________________________________
3. Gabapentin: ___________________________________________________
4. Omeprazole: __________________________________________________
5. Metformin: ____________________________________________________
6. Sertraline: ____________________________________________________
7. Atenolol: _____________________________________________________
8. Plavix: _______________________________________________________
9. Coumadin: ____________________________________________________
10. Zantac: ______________________________________________________
Hlth 243/F23/charting#1/ela
Due: Wed, 10/4/23 @ 0900
__________/15 points
Drug Classifications
Page
4
Match the classification of drug to the correct definition. 2 points
#
Classification
Definition
Analgesic
1. reduces fever
Anesthetic
2. lowers blood glucose levels
Antacid
3. treatment of manic-depressive episodes
Antianxiety
4. increases urinary output
Antiarrhythmic
5. relaxes blood vessels, lowers blood pressure
Antibiotic
6. loosens/promotes bowel movements
Anticholinergic
7. acts to prevents action of histamines
Anticoagulant
8. destroys or inhibits growth of microorganisms
Antidepressant
9. relieves pain without loss of consciousness
Antidote
10. neutralizes acid
Antiemetic
11. dilates bronchi
Antihistamines
12. prevents/controls coughing
Antimanic
13. produces lack of feeling, either local or general
Antihypertensive
14. controls/stops bleeding
Antineoplastic
15. produces calming effect without sleep
Antipyretic
16. reduces nasal congestion and swelling
Antitussive
17. counteracts effects of a poison
Diuretic
18. prevents/controls clotting
Hypoglycemic
19. facilitates removal of bronchopulmonary secretions
Sedative
20. controls cardiac arrhythmias
Contraceptive
21. prevents/relieves symptoms of depression
Hypnotic
22. prevents/relieves nausea and vomiting
Bronchodilator
23. constricts vessel and elevates blood pressure
Decongestant
24. reduces mental anxiety and tension
Expectorant
25. prevents replication of neoplastic cells
Hemostatic
26. controls high blood pressure
Laxative
27. blocks parasympathetic nerve impulses
Vasodilator
28. device/method that prevents conception
Vasoconstrictor
29. produces sleep
Hlth 243/F23/charting#1/ela
Due: Wed, 10/4/23 @ 0900
__________/15 points
Purchase answer to see full
attachment
