Associate Level Material
This assignment is for you to create a screening tool for potential hires in your health care facility. As the health care administrator, you would want to ensure that your future employees have a strong understanding of medical reports and medical terminology. You are writing these reports for the applicants to read, interpret, and answer a set of questions you have developed. Refer to the samples of medical records reports on pages (142-144, 196, & 261-263) of the textbook. Each medical record should be completed and contain two questions you would ask of the potential hires.
The following suggestions will help you get started:
• For the Impression/Discussion, indicate the patient diagnosis and what the plan is for his or her. This includes treatment, preventative measure to take, or follow-up.
Templates provided on the following pages.
Use the following templates for the assignment. Complete each section, save, and then submit as an attachment.
|Chapter 3 – Medical Record |
|History of Present Illness |
|The patient is a 26-year old male who has experienced mild rectal bleeding two days before admission. He has stated that over the |
|last two days he has had an urge to defecate so he has been rushing to the restroom non-stop. Today, the urgencies were too severe |
|so he reported to the emergency room to be seen. |
|Past Medical History |
|The patient’s medical history contains a few broken bones. A history of allergy illness due to eating peanuts. The patient was |
|presumed healthy up until this point. |
|Physical Examination |
|Temperature 99.8, pulse 91, respiratory rate 40, blood pressure 141/91. Patient is settled in bed. With complaints of being |
|uncomfortable. The abdomen is tender. The patient has had blood in his stools and blood was...