HSNS 171 : Fundamentals of Nursing Practice Case Study - Medical Science Assignment Help

Assignment Task:

Task:

Complete Part A, Part B, and Part C and submit your response below. You should review Chapter 16- Documentation in your Kozier and Erb’s textbook prior to commencing this assessment.

Part A (Evaluation) 500 words I have 575

Review the case of Mr. John Smith and the progress note entry provided. Evaluate the nurse’s documentation and discuss what information was-written well and the areas that could be improved. You will need to support your response to Part A from academic sources using APA referencing

Part A - Case study

Mr. John Smith, who is 80 years old, was admitted in medical ward this morning for consistent back and shoulder pain. He has a past medical history of hypertension (90mmHg/140mmHg) and type 2 diabetes mellitus. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain. He is scheduled for an MRI tomorrow.  You read the following entry by a previous nurse: The process of making an entry on a patient record is called recording, charting, or documenting. Healthcare organisations use different type of systems or forms for documentation; however, the purposes are the same. Communication between health workers; the ability to plan for patient care; source for research; educational tool; audit records for quality assurance; health care analysis; professional conduct; and legal documentation (Kozier, et al., 2012 p. 289-290). 69

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