ASSESSMENT TASK:
 Nursing Review Writing Assessment Answer 

Review the medical record attached and provide a detailed response to each question or activity outlined below.

You should support each of your responses with evidence and a citation of where in the medical record you have taken the information from. Wherever necessary, you should also provide an explanation of your reasoning (you can also use external reference material such as medical dictionaries and published texts to support your answers).
As always, you should observe all academic policies regarding plagiarism and referencing.
 

Questions / Activities

  1.  Put each of the events documented in the record into chronological order.
  2.  Based on the documentation, identify the main reason for the encounter.
  3.  Which body system does this condition pertain to? Briefly describe the structure and physiology of this body system and identify how and where this condition sits within it.
  4.  Is the condition referred to by any other synonym in the documentation? If so, identify what these are.
  5.  Does the record identify any other conditions that the patient had? What were they?
  6. Were these conditions present when the patient was first admitted or did they arise during the episode?
  7.  Which body system(s) do these conditions pertain to?
  8. Were these conditions, condition’s in their own right, or were they symptoms of other conditions documented elsewhere in the record?
  9.  Identify and expand all abbreviations and acronyms that were used.
  10.  List any clinical observations identified in the documentation. Of these observations, which of them could be considered ‘normal’ and which of them ‘abnormal’? Of the abnormal conditions, did any of them require care, monitoring or intervention?
  11.  What happened to the patient during the admission? What treatment and/or medical interventions did they receive?
  12.  Which interventions were linked to which diagnosis?
  13.  Was there any part of the documentation that you thought might require further clarification by the treating clinician? How would you frame your query to them?

 

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  • Posted on : November 23rd, 2018

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