Question

H214 Charting Du Print out worksheet and complete Each charting notation must be handwritten, in BLACK Ink Please do not use a computer for this exercise Turn assignment in folder on 5/9/16 at beginning of class will not be accepted through Canvas) A. Document in the place provided the pt's CC, with the information provided. Pt's name & DOB Date and Time you (as the SMA) are filling out the charting Do not forget to sign the charting Hint: What is key elements that need to charted for the ot's medical record? Patient: Tina Turner 9/4/81 Tina is in today because she is having cold symptoms. She has been stuffy for the last 5 days, has tried several over the counter meds with minimal relief. She is now having trouble sleeping, is having to mouth breath, her throat is starting to feel scratching and irritable. Tina believes she saw white spots on the back of her throat. She tells you that she is also blowing her nose constantly, and is starting to notice a red tinge in her tissues. Tina states that she has been coughing up green/white phlegm. The coughing happens all day, all night. She apologizes for being so graphic. She also mentions a temp of 100.8 to 101.9 degrees. C. Complete the 4 squares to the best of your ability regarding Tina Turner List a possible Pathophysiology for the patient? > Possible Psychological/Emotional Factors for the patient? • What are influencing factors for the patient? Social, financial, psychological, physical? → What are some possible biases in this scenario that an MA may have? (Yes, you may not have any, but what could be some possible biases that others in the healthcare field may have) Pathophysiology: Psychological/Emotional Factors: Your blases in this scenario. Influencing Factors: D. Rooming the patient: Responsibilities of Medical Assistant How would you prep Tina Turner for the exam for the doctor? Be specific a) Vitals: b) Positions & Draping: c) Lab/Diagnostic Tests:

Answer 1

1.Pathophysiology-Due to exposure to allergen inflammatory response took place in the body,leads to release of inflammatory mediators,leads to over secretion of mucus in nasal cavity and also hypertrophy of turbinates,this may lead to nasal obstruction and mouth breathing.The postnasal drip of the secretions from nasal airway,irritates the throat and leads to frequent cough and pharyngitis.

2.Psychological and emotional factos-Stress either in home or work place,over health consciousness, Anxiety, depression.

3.influencing factors-Obesity, environmental facors such as climate change,exposure to allegens , food habits.

4.Possible biases-May be treated as infection despite

managing actual cause.,Neglectance as a minor problem, failure to address the psychological and emotional factors.

D.Rooming the patient

1.Vitals-check for hyperthermia and hypoxia

2.Position and draping-upright or semifowlers position can be given

3.Lab test-Complete blood count including ESR, Absolute eosinophil count,CRP to rule out infection