Question Answered step-by-step Activities: Documentation These items were all found on real… Activities: DocumentationThese items were all found on real medical records: Select 10 items on the Communication Documentation Activity to correct. ? “unresponsive and in no distress”? “nonverbal, noncommunicative and offers no complaints”? “irregular heart failure”? “The need to maintain dialogue with the family regarding the appropriateness of limiting futile care to the patient is noted”? “his Hct is stable but dropping”? “I don’t want to be incubated again”? Indication for CXR: “coffee bean emesis”? “increased worriation”? “V/Q scan was positive for low probability”? “pt was apprehended and guarded”? “pulses are fixed and dilated”? in asking about code status”do you want your wife to receive artificial insemination”? “Findings compatible with ileus. Bladder is still in colon”? “be sure to check eyes and nose” (Is and Os)? “unemployed cashier”? Reason for leaving AMA: “pt wants to live”? “I had a kiwi on my chest” (keloid)? “dictated home O2, transcribed homo too”? “I have hemorrhoids & the Fitzgeralds”? “that bacterial virus is a doozy”? “noncompliant smoker”? “homodynamic compromise”? “denies any rectal breeding”? Indication for an EGD (written by a physician): “stomach hurt, swallow face in the morning, her poop is black & diabetes”? “spucus”? “fireballs in the uterus”? Reason for office visit: “FU chest rumbles”? “partial TAH”? Nursing notes in the ICU: “MD @ bedside attempted to urinate”? “titrate Tridil to pain”? Indication for flex sig: “blood when whipping himself”? “chicken pops”? “if she wants children, think about recommending birth control pills”? “polynephritis”? “holy systolic murmur”? “pt expired and was dc’d home”? “Pt has looked cachectic for the past 3 days”? “She diuresed pretty well. I gave her 40 of Lasix and she put out 2000 liters.”? “My back has been hurting ever since they gave me that cauterizer.” (Foley catheter)? discharge dx=nephrolithiasis; discharge instructions=”drink plenty of urine”? “Her CHF got much better with diaphoresis”? “She did not lose control of her rectum”? Plan: “gently dehydrate”? “allergic to Sulpher”? “platelets 1889dx thrombocytopenia”? “essentially tremors”? “nursing home called for pt acting lethargic”? “microalbumin anemia”? “pt is 95% blind”? Chief complaint: “bazaar behavior”? “GERP”? “depakote shot for pain”? “albeauty inhaler”? “I follow him for his paranoia”? “We will watch her diarrhea closely”? NH order: “check pulse everyday”? Allergies: “yes”? “They took a 50 cent piece out of my colon” (hemicolectomy)? “She has encephalitis of her right leg.”? “It has been decided to stop Vancomycin IV since we would need a PICC line and the patient, like many people who have PICC lines might pull the line out.”? “The surgical team was contracted for a cecal mass.”? “I need a colectomy because I have pollen in my colon.”? “This is a 981 YO female with a host of medical problems.”? “The patient is actually a fairly reliable historian.”? “hyperglycemia toe”? “brachycardia”? Order: “DC home when strong”? “pt was given a banana bath”? “acid peptic disease”? “The patient is difficult historian. The question is as to what is going on with the patient.”? “This is a 75 YO type 2 hypertensive”? Order: “Please feed patient only when awake.”? “Check orthostasis while on the floor”? “She is to wear STD stockings”? Order: “aspiration prophylaxis”? Order: “PT/OT eval STAT”? “nonaudible wheezing noted”? When asked if she had a discharge, the patient said “No, but I have Blue Cross Blue Shield.”? “Yes, I just met the Infectious Waste doctor.”? Nurse to doctor: “I just want to let you know that this lady has had decreased urinary intake.” (Doctor aware)? “He is allergic to wives.”? “No clubbing, cyanois, or extremities.”? “Renal insufficiency. IV Lasix was used to perfuse the kidney.”? Order: “Incentive spriometry Q 1 hour until awake.”? “fibromyalgia rheumatica”? “Pleasant man lying comfortably in bed. Appears somewhat uncomfortable”? “Her stomach showed 3+ edema up to the knees.”? “Will hold glyburide for now because of reverse hypoglycemia.”? “pneumonia left femur”? “2-4 packs of whiskey QD”? “Pt is on clonidine, not” Health Science Science Nursing NURS 3208 Share QuestionEmailCopy link Comments (0)