Question

4. Alicia, a medical assistant in Dr. Howard's office, has recorded the following in a patient assessment: "CC: Pt. c/o fatigue, depressed mood, and inability to stay asleep at night. He has taken Tylenol PM for two nights with no effect" on sleep and has not eaten for 2 days because of lack of appetite, which is likely caused by his depression. His face is pale and his skin clammy." Was there anything in this documentation that should not have been recorded? Explain your answer.

Answer 1

One thing that should not be recorded in the documentation is " Tylenol taken for 2 nights with no effect on sleep", because Tylenol/acetaminophen which is actually taken for fever, cold, allergies, head aches, muscle aches etc. Here patient is with fatigue, depressed and inability to sleep, where Tylenol actually will not show any effect on patient symptoms.