A 50-year-old woman has been experiencing a chronic cough for the past two months. She is a two pack a day smoker and has been for the past 30 years. She sees her PCP for the cough and is given an order for a chest x-ray at the local hospital. The x-ray report states “nodule in lower lobe of right lung, worrisome for malignancy.” The PCP refers her for a biopsy of the nodule at the ambulatory surgery clinic which substantiates the diagnosis of cancer in the pathology report. Two weeks later, the same physician who did the biopsy performs a right lower lobectomy. Prior to discharge after surgery, the patient develops an infection and the infectious disease specialist is asked to evaluate her and recommend the appropriate treatment course. Upon discharge, she receives care in her home for the next two weeks. Four weeks after surgery, radiation therapy is initiated, but her condition continues to deteriorate over the next few months with metastasis to the brain noted, at which point she decides to receive only palliative care.
1. Classify the providers for each stage of the patient’s care noted above and outline their responsibilities.
2. Explain the documentation that each provider will be creating as part of the patient’s record.
1. According to each stages of patient's care the providers are classified as( along with their responsibilities) -
A) Doctor- includes history taking( two pack a day smoker and has been for the past 30 years and experiencing a chronic cough for the past two months. ) and physical examination and referral to laboratory investigation. ( pcp for cough and x ray)
B) Radiologist- includes x ray findings and interpretation. (X-ray report states “nodule in lower lobe of right lung, worrisome for malignancy.)
C) Pathologist- findings of biopsy and briefly evaluation (biopsy of the nodule at the ambulatory surgery clinic which substantiates the diagnosis of cancer )
D) Surgeon- use of aseptic technique and informed consent maintaing all the ethical aspect. And administration of drugs according to condition of the patient.
E) Nurse- preparation for termination phase and end of nurse patient relationship with health talk regarding her present condition and home care.
F) Oncologist- for providing proper radiation therapy to prevent further growth of abnormal cell and metastasis.
E) finally in the palliative care nurse and doctors both involve in symptomatic management and end of life care.
2. Documentation from each provider as a part of patients record-
A) Doctor- subjective data ( experiencing a chronic cough for the past two months. She is a two pack a day smoker and has been for the past 30 years. ) and objective data ( physical assessment involves abnormal breath sound and respiratory rate and depth)
B) Radiologist- observe and document nodule in lower lobe of right lung, worrisome for malignancy.
C) Pathologist- document the findings that PCP refers her for a biopsy of the nodule at the ambulatory surgery clinic which substantiates the diagnosis of cancer in the pathology report.
D) Surgeon- document the date and time of surgery ( right lower lobectomy) , any complication , use of anasthesia and other medication during surgery and other post op medications .
E) Nurse- document the change in temperature and vital signs during infection.. During dicharge the nurse will document the type of discharge , dicharge medications which are given from the hospital and signature of available patient relative or patient ownself.
F) Oncologist- document the type of radiation therapy and time taken for completion, frquency of receiving radiation therapy and it's side effects and abnormalities (metastasis to the brain noted, )
A 50-year-old woman has been experiencing a chronic cough for the past two months. She is...
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