Answered: READ THE FOLLOWING CASE SCENARIO.…

Essentials Health Info Management Principles/Practices

4th Edition

ISBN:9780357191651

Author:Bowie

Publisher:Bowie

Chapter6: Patient Record Documentation Guidelines: Inpatient, Outpatient, And Physician Office

Section6.5: Physician Office Record

Problem 2E

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READ THE FOLLOWING CASE SCENARIO. ANALYZE AND IDENTIFY THE TYPE OF (1) ASSESSMENT NEEDED, (2) THE SUBJECTIVE, AND (3) THE OBJECTIVE DATA OF EACH SCENARIO. CASE SITUATION #1: Phyllis Johnson brings her 2-year-old daughter, Lauren, to the emergency department (ED) with a fever of 103°F. Mrs. Johnson states that Lauren has had a cough and runny nose for the past 2 days and is not sleeping or eating well. Lauren is irritable, tugs at her ear, and says, "my ear hurts." Lauren's old records show that she has been treated three times over the past year for otitis media. CASE SITUATION #2: Mr. Michael is 51 years old. He was admitted two days ago with chest pain. His physician has ordered the following studies: electrocardiogram, chest x-ray, and complete blood studies including blood sugar. These studies were just posted on the chart. When you talk with him, he states, "I feel much better today- no more pain. It is a relief to get rid of the discomfort." You think he appears a little tired or weary- he seems to be talking slowly and sighs more often than you would think is necessary. When his wife comes to see him, she is cheerful with him but confides in you he seems depressed or something. His vital signs are BT- 98.8°F, BP: 140/90, PR: 74, and RR: 22. CASE SITUATION #3: You have a 48-year-old male patient who comes in stating, “I feel like I can’t breathe.” Patients’ respirations are 28 breaths per minute and their heart rate is 115 beats per minute. The patient then grabs his chest and says, “My chest hurts so bad, please help!” You ask the patient to rate the pain on a scale from 0-10, 10 being the worst pain ever. The patient replies, “10, it hurts so badly!” You then ask the patient to describe what the pain feels like, the patient reports that his pain feels like pressure. Your patient then starts to become diaphoretic and pale. You take an EKG that shows Sinus Tachycardia. The pulse oximeter shows 100% on room air and the patients’ blood pressure is 120/80 mmHg.

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