Question

1. You are a nurse providing care for a young woman who was involved in a motor vehicle accident. She is brought to your emergency department via ambulance, where your trauma team is in the midst of examining and assessing her. From the initial assessment, her vital signs are measured; she is unconscious with shallow breathing, exhibits several abrasions, is bleeding from a wound in her left thigh, and moans frequently. An intravenous line has been started in her right antecubital vein and normal saline is infusing. (Learning Objective 5) a. Where would you expect to document this information? b. Which topics in the narrative would you expect to be included in proper documentation? C. Which type or model of documentation best suits this type of information? d. What important type of thorough information is missing in the case study? e. Itemize the additional information that should be included. f. What are the benefits of an electronic medical record (EMR) for a patient who is unconscious?

Answer 1

a.

Accidental and trauma cases are majorly a part of emergency department practice. Documentation of the initial findings for any patient with trauma is done under the patient presentation and case presentation record. This record is maintained as the initial record wherte the findings of the patient wheen he or she is admitted to the facility is done. This enables the health care professionals to document and report the trauma cases well. This will be well documented in Medical history record.

b.

Documentation is a crucial aspect of health care, and providing information is the part of the patient but recording valid and crucial information is upto the skills of the professionals, therefore, in this case the details regarding the patient's vitals signs, consiousness level, injuries, and clinical presentation would be included in proper documentation.

c.

There are different types of medical and nursing documentation and as per the use and purpose the documentation is carried out. IN this case these infromation will be best documented using the medical documentation model where the medical history of the patient is recording, from admission to discharge.

d.

Several infromation are required in the health records, lack of any crucial information can lead to poor care. IN this case study the thorough and crucial information that is lacking is the history of medical illness and allergies to the patient.

e.

The given case study is not proper narration of complete health record of the individual, it lacks many infromation such as, history of past illness, medical hsitory, family history, allergy history, habits etc.

f.

Electronic medical recording system is the computerized syustem use to feed patient ehalth records and manage it through technology. Electronic health records are beenficial in the case of patient who is unconscious as the patient cannot provide their past medical history but the previous records of their health can be achieved from old data stored in EMRS.