Documentation Components Course Work Essay.

Documentation Components Course Work Essay.


To obtain the hospitalization records for this patient, the inpatient number of the patient will be obtained from the patient’s discharge summary following which a call will be placed to the records department of the hospital where the patient had been admitted and a request for the patients inpatient file be made. A record clerks will deliver the patient’s file to the office or alternatively, a records clerk will be sent to get the patients inpatient file from the records department of the hospital where the surgical operation was performed (Saxton & Leaman, 2011, p.174).
The physician will be interested in the patients continuation/progression notes for the following periods; pre-op, intra-op and post-operatively.


Further, he will be interested in seeing the patient’s treatment sheet. Further, he will like to see the results of any investigations ordered by the gynecologist such as full hemogram; ultrasound amongst others so as to determine the condition of the patient both pre and post-operatively with an aim of determining the best management plan for this patient. The physician will also be interested in seeing the form on informed consent that the patient had signed prior to being taken to theatre. In addition, he will want to see the anesthetist’s records during and after the operation. Moreover, he will want to evaluate the patient’s input-output charts, observations of blood pressure, temperature, pulse and respirations charts. The physician will also be interested in reviewing the nursing notes for the patient especially the cardex since it contains vital information regarding the patient’s condition before, during and after the operation (McArthur-Rouse & Prosser, 2007, pp.6-11).
Patient progression notes will detail the patient’s history in terms of the history of presenting condition, past medical surgical history, socioeconomic history, developmental history and past and current obstetric history. Further, it will provide details of the physical examinations that had been performed on the patient. More importantly, they will entail the diagnosis that the gynecologist arrived at after reviewing the patient as well as the findings of investigations ordered such as ultrasound and full hemogram. Further, they will provide details of the management plan for the patient both pre and post-operatively including the type of surgery that was done. The patient’s treatment sheets will provide details on the type of drugs, dosage, route of administration as well as the duration for taking the drugs that the patient had been prescribed both pre and post-operatively. Details embodied within the form of informed consent include the patient’s signature consenting to the planned surgical operation. Basically, the patient signs the form after the gynecologist has provided an explanation on the diagnosis as well as the need for and details on the planned surgical operation. The surgeon to conduct the operation also countersigns the informed consent form (McArthur-Rouse & Prosser, 2007, pp.6-11).Documentation Components Course Work Essay.
Details encompassed within the anesthetist’s notes include the type of anesthetic agents used during the surgery and how they were administered either intravenous, spinal or via inhalation, time the anesthesia was commenced and when it was stopped as well as the pre and post-operative diagnosis. The patient’s input-output charts will entail details of the amount of fluids the patient had taken either orally or given intravenously during the period she had been admitted and the corresponding amount of output in terms of urine and vomiting amongst others. Patient’s observation charts will provide details on the monitoring of the patients vital signs to include temperature, blood pressure, pulse and respirations for the period the patient had been admitted. These details are vital because they provide insight into the condition of the patient. The nursing cardex will provide details on the nursing management of the patient to include health education provided to the patient in regard to the disease condition and its management, details on the patient’s per vaginal bleeding during the inpatient stay, patient’s level of pain, patient’s general condition prior, during and after the surgery (Dodge & Kneedler, 2007, pp. 341-343).Documentation Components Course Work Essay.


Dodge, G.H. & Kneedler, J.A. (2007). Perioperative patient care: the nursing perspective
(5th ed.). Sudbury, MA: Jones and Barlett Learning, Inc.
McArthur-Rouse, F.J. & Prosser, P. (2007). Assessing and managing the acutely ill surgical
patient. Malden, MA: Blackwell Publishing Inc.
Saxton, J.W. & Leaman, T.L. (2011). Managed care success: Reducing risk while increasing
patient satisfaction (2nd ed.). Maryland, MA: Aspen Publishers, Inc.Documentation Components Course Work Essay.