
Concept explainers
To discuss:
Can you identify essential information that must be documented in Mrs. P’s electronic record regarding her cardiac condition and treatment?
Case summary:
Mrs. P is a single, 88-year-old woman, was hospitalized for cardiac problems. She has been at the beginning of dementia. She lives alone in a small home along with her cats. When she was ordered for the discharge, the nursing student worried about Mrs. P’s ability to live safely on her own. The nursing student suggested her about moving to a retirement community or long-term care facility. But Mrs. P refused those options. The nursing student concerns about her safety and reported to the charge nurse. The charge nurse replied that we can do nothing if the patient is not willing to explore the other options.
To discuss:
Why is it considered to be important in documenting the assessment of the patient’s current mental health status?
To discuss:
Could you find any other essential information which supports safe patient care and that should be included in the electronic record?
To explain:
Does the hospital or unit have a program where the patients are called for a follow-up?
To explain:
Would Mrs. P follow up with her primary care provider?
To explain:
What documentation would found to be useful for these teams?

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