Question

Mr Tim Williams, 56 years, is hospitalised for management of symptomatic pernicious anaemia. He exhibits shortness of breath, looks pale and reports numbness and tingling sensation in the palms and soles of his feet. Oral intake has been poor over the last week due to nausea. Haemoglobin levels are 74g/L, with abnormal electrolytes. The doctor has ordered some medications and IV hydration to manage the situation.

How to write a patient note for Administering medications and IV fluids as prescribed. IV pumps are not available and therefore, you have to administer hydration via gravity set.

Answer 1

To write a better patient notes is by using the SOAP tool

Subjective: 56yr female with complaints of numbness and tingling sensation in the palms and soles of his feet.,nausea

Objective :pale,shortness of breath, Hb7.4gm(in pernicious anemia), abnormal electrolyte levels

Assessment:Pernicious anemia

Plan:Medications to raise hemoglobin level

IV fluids via gravity set for rehydration