3. Identify the acute-care record component where the following… 3. Identify the acute-care record component where the following information would be found. A patient states that he has experienced difficulty swallowing for the last two weeks. Neck: supple. Carotid pulses 2/7. Slight Jugular venous distention is noted. Date: 6-2-2014 Admit via internal medicine. Urinalysis, Cardiac diet. I have recommended to Mr. Patient that we proceed with CT scan of head to rule out bleed. Thank you for allowing me to participate in Mr. Patient’s care today. Time: 0120 Temperature 36, Pulse 144, Respiration 46 PT: 17.6 H, INR: 1.9, PTT: 32.0H=High Exam Date: 12/8/15Check in# 15Exam# 42589PA and Lateral Chest: 12/8/15Findings: The lungs are clear Date: 6/8/15Surgeon: Dr. AnyoneAssistant: NoneAnesthetic: SpinalComplications: NoneOperation: Right Carotid Endarterectomy Disposition: No lifting greater than 15 lbs. No driving for 6 weeks. Final Diagnosis: Coronary Artery Disease Activity: Up in chair 0700 6/19/15Hygiene: ShowerNutrition: 2/3 eatenIV Pump: D/C 38 weeks gestation, Apgar’s 8/9, 6# 9.8 oz. good cry, to room with mom Health Science Science Nursing PSY* 100 Share QuestionEmailCopy link Comments (0)
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