How to Complete a Medical Chart
Medical Chart
Name Nick Morris Age 17 Gender M
Date September 9, 2021
Chief complaint
Patient is carried into the ER by several friends. They say he passed out during a party and they don’t know what’s wrong with him. They are not sure how long he has been unconscious. They were asked if he had been drinking, and they say that he has been drinking all night. One friend says he seemed confused at one point.
Medical history
The patient is currently not on any medication.
History of tuberculosis at the age of 14 where he was admitted for one week.
Habits (tobacco, alcohol)
The patient smokes tobacco daily where he smokes almost a full packet.
He also drinks alcohol on daily basis.
Family history
He is the first born with two sisters.
His parents died two years ago making his uncle to take care of him together with his sisters.
No history of any chronic illness in the family.
Surgical history
History of surgery when he was 13 years old after being involved in a road accident leading to fracture right femur.
Medications
The patient is currently not on any medication.
Allergies
Allergic to penicillin medications.
History of food allergy where he is allergic to eggs.
Physical Exam
The patient is unconscious and appears weak. There is no any abnormality with the head. The chest is normal but with abnormal breathing pattern. The respiration rate is slow where the patient is having a respiration rate of 16 b/m. there is no any abnormality noted on the patient’s abdomen. The patient has a scar on his right leg due to fracture femur.
Discussion Questions
- How does a medical chart help diagnosis and treatment?
The medical chart gives relevant objective and subjective data that help in coming up with the possible causes of the condition that the patient presents with. Through medical, surgical, and family history, the medical profession can rule out other conditions related to the main condition, leading to the right diagnosis being made. Objective data and subjective data from the medical chart are also used to plan for care provided to the patient. Priority care is identified based on the subjective and objective data findings.
- How might incomplete information on a medical chart cause a misdiagnosis of the problem or condition or delay treatment that could be life-saving? In Nick’s case, his friends could provide information on what he had been doing prior to his visit to the Emergency Room. What if Nick’s friends could not provide complete information? How would this affect his care?
Incomplete information can lead to misdiagnosis since relevant information, such as past medical history and medication, is left out. All relevant information associated with the patient’s condition should be captured to help make the right diagnosis and administer the right treatment. If Nick’s friend cannot provide complete information, Nick may end up being given medication that may worsen his condition in case he has a serious medical condition. Complete information prevents medication errors, which may lead to complications.
References
Sheriffdeen, A., Millar, J., Martin, C., Evans, M., Tikellis, G., & Evans, S. (2019). (Dis) concordance of comorbidity data across ICD codes, medical charts, and self-reports.
Silvestre, C. C., Santos, L. M. C., de Oliveira-Filho, A. D., & de Lyra, D. P. (2017). ‘What is not written does not exist’: the importance of proper documentation of medication use history. International journal of clinical pharmacy, 39(5), 985-988
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Question 
How to Complete a Medical Chart
For a patient who has alcohol poisoning. The patient demographics and chief complaint have been provided. Please invent the details for any components which do not require specific/accurate facts.
- Include all the components of a medical chart.
- Use accurate information for the symptoms the patient would be experiencing.
- Answer the discussion questions at the end of the chart using correct grammar and accurate information. Write a 1-2 paragraph response for each question.
- Use references; remember to use APA format and cite your information.
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