Ghazvini- Medical Records PPT

Sodium (Na) reference range:

135-145 mEq/L

Potassium (K) reference range:

3.5-5.0 mEq/L

chloride (cl-) reference range:

95-107 mEq/L

carbon dioxide (CO2 total bicarbonate) reference range:

22-29 mEq/L

blood urea nitrogen (BUN) reference range:

7-20 mg/dL

creatine (Cr) reference range:

0.6-1.4 mg/dL

glucose reference range:

70-110 mg/dL

albumin reference range:

3.4-5.0 g/dL

Alkaline phosphatase (ALP) reference range:

41-133 IU/L

Alanine aminotransferase (ALT) reference range:

anything less than 37 IU/L

Aspartate aminotransferase (AST) reference range:

anything less than 35 IU/L

Calcium (Ca2+) reference range:

8.5-10.5 mg/dL

total bilrubin reference range:

0.1-1.3 mg/dL

total protein reference range:

6.0-8.0 g/dL

WBC reference range:

4,500-10,000 cells/uL

Hemoglobin (Hb) reference range:

males: 13.6-17.5 g/dL

females 12.0-15.5 g/dL

Hematocrit (Hct) reference range:

males: 41-50%

females: 35-46%

platelet count reference range:

150,000-400,000 platelet/uL

red blood cell (RBC) count reference range:

males: 4.7-6.1x10^6 cells/uL

females: 4.2-5.4 x10^6 cells/uL

what are the components of a patient chart? (6)

1. medical history

2. Laboratory test results

3. diagnostic test results

4. problem list/assessment

5. clinical notes

6. treatment notes/plan

what goes under medical history (history & physical , h&p)?

patient demographics

chief complaints -(CC)

history of present illness- (HPI)

past medical history- (PMH)

Family history -(FH)

History- (SH)

what goes under clinical notes?

Progress notes, consultation notes, discharge summary

what goes under treatment notes/ plan?

medication orders, MARS (medication administration records)

what of the patient has allergies?

-check to see about previous allergy reactions

-check to see nature/significance of past allergy reactions

-are there any potential allergies existing

-is there drug intolerance

-are there side effects from those drugs? if so, what drugs and what were the rxns?

what goes under medication history?

-what medications, ROAs, doses, and duration of tx are present?

-have those medications worked in the past?

-are those medications hindering to any of the medical problems?

-has the past drug therapy been a success or failure?

-any adverse effects?

-immunization history?

what goes under physical examinations?

vital signs, observations/ results of any exams done

what is included in the lab test results?

basic metabolic panel

complete blood count (CBC)

cardiac enzymes

serum conc. for certain drugs

what is included in problem list/ assessment?

1. prioritized problem list and drug related problems

2. drug related problems (DRPs)

what are prioritized problem list and drug related problems?

active problems for the patient, usually numerically prioritized according to severity. usually the problems that usually stem from the chief complaint are the highest acuity.

what are the drug related problems ?

these are problems that are associated with and given as SUB- bullets to each problem. They identify is a drug therapy in contributing or interfering with desired outcomes. EX: adverse rxns, drug-drug rxns, drug-disease interactions, sub-optimal therapy, or dosing

what goes under the treatment notes/plan?

Final Treatments:

1. Nonpharmacological

2. Pharmacological

Provide justification, education and counseling

ROS general:

usual weight, recent weight change, weakness, fatigue, fever, night sweats, anorexia, malaise

ROS skin:

color changes, pruritus, bruising, petechiae, infections, rashes, sores, changes in moles, change in hair or nails

ROS head:

headache, head injury

ROS eyes:

vision, glasses , contacts, date of last eye exam, pain, redness, excessive tearing, double vision (diplopia)

ros ears:

hearing less, change in hearing, ringing in ears (tinnitus), ear infections

ros nose and sinuses:

frequent colds, nasal stiffness, hay fever, nosebleeds (epistaxis), sinus trouble, obstruction, discharge

ros mouth and throat

soreness, dryness, pain, ulcers, sore tongue, bleeding gums, pyorrhea, teeth

ros neck

lumps, swollen lymph nodes, glands, goiter (thyroid enlargement)

ros breast:

lumps, pain, nipple discharge, self exam, enlargement in men or children

ROS: Pulmonary

Cough, wheezing, change in cough, double breathing

ROS: Cardiovascular

Palpitations, hypertension, known heart disease, history of murmur, syncope or near syncope

ROS: Gastrointestinal

Appetite changes, painful swallowing, difficulty swallowing, jaundice, nausea/vomiting, heartburn or reflux, changes in bowel habits, changes in stool color/caliber/quantity, pain, blood with bowel movement and location of blood.

ROS: Urinary

-Frequent urination

-Burning

-Blood

-Difficulty starting urination

-Difficulty controlling your urine

-Able to empty bladder

-Unable to empty your urine

-Have you kidney stones

ROS: Musculoskeletal

joint pain, muscle pain, backache, stiffness, arthritis

ROS: Neurological

headache, syncope, seizure, numbness, focal weakness

ROS: Psychiatric

Description of mood

Nervousness

Anxiety

Depression

Stress/tension

Memory loss

Confusion

Hallucinations

Suicidal thoughts/attempts

ROS: Endocrine

"Thyroid trouble," heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size.

ROS: Hematologic

Anemia, easy bruising or bleeding, past transfusions, transfusion reactions