Country : Australia
Assignment Task :

Only the progress notes evaluation in Part A and Part B will be referenced. Use your Kozier and Erbs and the NSW Health 

Documentation management guide as references. It's up to you on how many references you want to use but always try to Task 1 (500 words)

Complete both Part A and Part B and submit your response below. You should review Chapter 16- Documentation in your Kozier and Erb’s textbook prior to commencing this assessment.

 

Part A

Review the case of Mr John Smith and the progress note entry provided. Evaluate the nurse’s documentation and discuss what information was-written well and the areas that could be improved. You will need to support your response to Part A from academic sources using APA referencing

 

Part A - Case study

Mr. John Smith, who is 80 years old, was admitted in medical ward this morning for consistent back and shoulder pain. He has a past medical history of hypertension and type 2 diabetes mellitus. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain. He is scheduled for an MRI tomorrow.  You read the following entry by a previous nurse:

 

Part B

Review the case of Sharon and the progress note entry provided. Evaluate the nurse’s documentation and discuss what information was-written well and the areas that could be improved. You will need to support your response to Part A and B from academic sources using APA referencing. After evaluating the progress note, you are to write your own progress note in a narrative format.

 

Task 2 - Rewrite the information in ISBAR format

Mary Skinner Snr. is a 56-year-old lady who lives at home with her husband Frank, their daughter Marie, three grandchildren, and one great-grandson. They live in a five-bedroom home and have regular visitors coming and going from the home. She has a past medical history of type 2 diabetes mellitus, which up until 1 year ago was well-controlled with diet and light exercise. She has been prescribed metformin for approximately 1 year to assist with her blood glucose level (BGL) control.

Mary has a close group of friends from her local church which she attends regularly. To stay active she often walks around the corner to the local shopping center to buy her groceries. Today she was on her way back from the shops when she tripped on the footpath and fell. A passer-by called an ambulance and she was taken to the emergency department (ED). She has been fast-tracked admitted to the hospital to prepare for surgery on her right hip. At 9 am in the morning, she arrives at the surgical ward and the RN accepts care of Mary and begins to the patient assessment.

 

  • Evaluate the patient information provided against the general guidelines for recording 
  • Rewrite patient information using a given format following the general guidelines for recording patient information 
  • Analyse patient information with reference to ISBAR format 
  • Rewrite patient information in ISBAR format  
  • Incorporate research-based evidence (in APA format) to support your argument. 
  • Record information using clear, understandable English, and appropriate medical terminology.

 

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