You are a nurse providing care for a young woman who was involved in a motor vehicle accident. She is brought to your emergency department via ambulance, where your trauma team is in the midst of examining and assessing her. From the initial assessment, her vital signs are measured; she is unconscious with shallow breathing, exhibits several abrasions, is bleeding from a wound in her left thigh, and moans frequently. An intravenous line has been started in her right antecubital vein and normal saline is infusing. (Learning Objective 5) a. Where would you expect to document this information? b. Which topics in the narrative would you expect to be included in proper documentation? c. Which type or model of documentation best suits this type of information? d. What important type of thorough information is missing in the case study? e. Itemize the additional information that should be included. f. What are the benefits of an electronic medical record (EMR) for a patient who is unconscious?
You are a nurse providing care for a young woman who was involved in a motor vehicle accident. She is brought to your emergency department via ambulance, where your trauma team is in the midst of examining and assessing her. From the initial assessment, her vital signs are measured; she is unconscious with shallow breathing, exhibits several abrasions, is bleeding from a wound in her left thigh, and moans frequently. An intravenous line has been started in her right antecubital vein and normal saline is infusing. (Learning Objective 5) a. Where would you expect to document this information? b. Which topics in the narrative would you expect to be included in proper documentation? c. Which type or model of documentation best suits this type of information? d. What important type of thorough information is missing in the case study? e. Itemize the additional information that should be included. f. What are the benefits of an electronic medical record (EMR) for a patient who is unconscious?
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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You are a nurse providing care for a young woman who was involved in a motor vehicle accident. She is brought to your emergency department via ambulance, where your trauma team is in the midst of examining and assessing her. From the initial assessment, her vital signs are measured; she is unconscious with shallow breathing, exhibits several abrasions, is bleeding from a wound in her left thigh, and moans frequently. An intravenous line has been started in her right antecubital vein and normal saline is infusing. (Learning Objective 5)
a. Where would you expect to document this information?
b. Which topics in the narrative would you expect to be included in proper documentation?
c. Which type or model of documentation best suits this type of information?
d. What important type of thorough information is missing in the case study?
e. Itemize the additional information that should be included.
f. What are the benefits of an electronic medical record (EMR) for a patient who is unconscious?
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