
1.
To discuss:
The information that should be documented electronically based on the assessment of severity of Xavier’s pain.
Case summary:
Patient X is a 5-year-old boy, who had been diagnosed with ulcerative colitis. While he was in the bathroom with his mother, he suddenly holds his stomach and starts to scream that his stomach is hurting very much. The patient’s mother pulls the alarm while his pain is increasing and needed assistance to get off the toilet. He received a smaller dose of pain relief medication that seems to take no action, while patient X still screams and lies in a fetal position while holding his stomach and says his pain seems never to go away.
2.
To discuss:
The any other essential information that are available that should be recorded in the patient’s X electronic record that should support safe patient care from the entire health care team.
Case summary:
Patient X is a 5-year-old boy, who had been diagnosed with ulcerative colitis. While he was in the bathroom with his mother, he suddenly holds his stomach and starts to scream that his stomach is hurting very much. The patient’s mother pulls the alarm while his pain is increasing and needed assistance to get off the toilet. He received a smaller dose of pain relief medication that seems to take no action, while patient X still screams and lies in a fetal position while holding his stomach and says his pain seems never to go away.

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