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Medical Record Project

Practicum Health Science I 2011 - 2012. Medical Record Project. Instructions: Complete the following in your class notebooks. Outline Chapter 4: Communicating with the Health Team – Mosby’s Textbook for Nursing Assistants Complete Worksheet: Communicating with the Health Team.

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Medical Record Project

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  1. Practicum Health Science I 2011 - 2012 Medical Record Project

  2. Instructions: Complete the following in your class notebooks • Outline Chapter 4: Communicating with the Health Team – Mosby’s Textbook for Nursing Assistants • Complete Worksheet: Communicating with the Health Team. • Review Power Points: Interviewing and the Health History, Communication and Health Care Provider Relationship, and Physical Examination and History Taking

  3. Application of Knowledge: Create A Medical Record • All information must be fictional. • Must be put together like a hospital chart. • Must have dividers for the sections of the chart. (You may make your own) • All entries must be dated, timed (in military time), and signed. No crossing out is allowed without initialing. Black ink only. • All pages must patient name, date of birth and medical record number.

  4. Outside of Chart Must include: Patient Name (last, then first) Room Number Doctor Allergy Sticker (Must be allergic to at least one medicine or food item) Code Status (Full/DNR; choose one)

  5. 1: Kardex Patient name, room number, doctor, date of admission, admitting diagnosis, allergies, weight, previous history (including surgeries), diet, activity, how often vital signs are taken, tests scheduled, labs to be done, procedures/surgeries to be done, safety measures, IV sites and fluids, respiratory/ oxygen therapy, isolation precautions, contact information, misc info-language, dentures etc.

  6. Sample Kardex • Sample Kardex

  7. 2. Sections of the Chart • Admission Data: Admission Sheet & Nursing History (Provided to You) • Consents: Consent to treat, consent for receiving blood, procedure or surgical consent. • Doctor’s Orders ( Must include one completed order) • Progress Notes – (Must include one completed Progress Note)

  8. Sections of the Chart • Flow Sheets: Vital Sign flow sheet and Intake and Output flow sheet. (Must include one flow sheet with at least 5 entries) • Lab results (Must include at least one set of lab results) • Reports: Operative reports, anesthesia record, x-ray reports (Include at least one)

  9. Samples • Sample consent form – Located on Wikispace page. • Sample MD Orders – Located on Wikispace page. • Sample Progress Note - Progress Note (Do not leave areas on progress note blank, or write refer to chart.), also p. 57 in Mosby’s Textbook for Nursing Assistants • Sample Flowsheet – p. 57-58 in Mosby’s Texbook for Nursing Assistants

  10. Samples • Sample Lab Reports - How to Read and Understand Medical Laboratory Results – wikiHow • Sample Anesthesia Record - Anesthesia Report • Sample Operative Record - Operative Record • Sample X-Ray Report - X-Ray Report l

  11. Due Date • Monday October 17, 2011

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