Chapter 26, Problem 1CAQ

Summary Introduction

To identify:

The data to be documented as an objective

Case summary:

Mr. D is an 80-year-old man who is admitted to the hospital for suspected pneumonia. The patient says that he is not feeling well and has cough, sputum which is thick and lightly tanned. The nurse checks the patients vital that shows 150/90 mm Hg with a pulse rate of 92 beats/min, and breathing  22 breaths/min. The patient coughs for about 45 sec, the nurse finds out wheezes in his lungs, the patient also states that his chest pain while coughing and it radiates to his shoulders. 

Explanation of Solution

The objective documentation describes the diseased condition of the patient, their vitals, and patient behavior. In the case of Mr.D, the objective documentation are his blood pressure of 150/90 mm Hg, pulse rate of 92 beats/min, breathing  22 breaths/min, and frequent cough.

Conclusion

The documentation of the patient in the medical records should be perfect and truthful, it should cover all the clinical finding of the patient. Since it will be helpful for the doctors and nurse who go through the medical records of the patients.