Medical Report

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Associate Level Material
Medical Report

This assignment is for you to create a screening tool for potential hires in your health care facility. As the health care administrator, you would want to ensure that your future employees have a strong understanding of medical reports and medical terminology. You are writing these reports for the applicants to read, interpret, and answer a set of questions you have developed. Refer to the samples of medical records reports on pages (142-144, 196, & 261-263) of the textbook. Each medical record should be completed and contain two questions you would ask of the potential hires.

The following suggestions will help you get started:

• Sometimes it is easier to start at the end. Think of the diagnosis the patient will receive. If you know what the end diagnosis will be, it makes it easy to know what symptoms, signs, and diagnostic methods would be used to achieve that diagnosis.

• For the History of Present Illness, consider what questions the physician might ask the patient about his or her chief complaint and symptoms and then chart that in this section. This section serves as an account of what the patient would report, based on their symptoms. Remember, symptoms are subjective, in that they are conditions experienced by the patient, and are therefore included in the patient history.

• For Past Medical History, document anything the patient may indicate in terms of past medical conditions that would be relevant to his or her current illness.

• For the Physical Exam section, document the observable signs. Signs are objective, in that they are measurable conditions, and therefore included in the physical exam. This includes vital signs or anything observed by performing the patient physical exam.

• For the Diagnostic/Lab Results, include the testing or procedures required to prove this diagnosis.

• For the Impression/Discussion, indicate the patient diagnosis and what the plan is for his or her. This includes treatment, preventative measure to take, or follow-up.

Templates provided on the following pages.

Use the following templates for the assignment. Complete each section, save, and then submit as an attachment.

|Chapter 3 – Medical Record | |History of Present Illness | |This is a 32-year-old Caucasian female was having severe (ab-DAWM-ih-nal) pain on the evening of admission. She was awakened by | |sharp pains in the (gastr/o). She took an (ant-AS-id) before leaving for work and had no relief throughout the day. She did eat | |lunch and shortly after developed (NAW-see-ah), (emesis), and an hour later she developed watery (dy-ah-REE-ah) with 4 | |(def-eh-KAY-shun) movements over the next few hours. The patient’s (orex/o) changed a couple of weeks ago. The patient complains of| |(dis-PEP-see-ah) after eating spicy foods. Patient denies any history of KROHN disease. By this evening her pain was so severe that| |she came to the emergency room to be seen. | |Past Medical History | |She has a past history of a (hy-AA-tal) (HER-nee-ah) in which a (her-nee-OR-ah-fee) was performed for correction. A hiatal hernia | |occurs when part of your stomach pushes upward through your diaphragm. Your diaphragm normally has a small opening (hiatus) that | |allows your food tube (esophagus) to pass through on its way to connect to your stomach. The stomach can push up through this | |opening and cause a hiatal hernia (Mayo Clinic, 2011). Patient has a past history of (gas-TRY-tis) and has been instructed from her| |Medical...
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