Essays /

Notepad Essay

Essay preview

College of Nursing

CASE PRESENTATION FORMAT
(GENERAL WARD)

I. Introduction

II. Purpose/Objective

- Learning a skill that you will use for your entire career -- and that skill is to be able to communicate in a way that enables you to present the patient to any other health-care provider in a concise manner.  It is like learning another language.

|LEARNING GOAL |STUDENT CENTERED |CLIENT CENTERED | |SKILLS | | | |KNOWLEDGE | | | |ATTITUDE | | |

III. Chief Complaint (CC)
- The opening statement should give an overview of the patient, age, sex, reason for visit and the duration of the complaint. Give marital status, race, or occupation if relevant.  If your patient has a history of a major medical problem that bears strongly on the understanding of the present illness, include it IV. History of Present Illness (HPI)

- Present the most important problem first
- If there is more than one problem, treat each separately - Present the information chronologically.  Cover one system before going onto the next - Characterize the chief complaint – quality, severity, location, duration, progression, and include pertinent negatives ...

Read more

Keywords

1 10 2 3 4 5 6 7 8 9 abl abnorm abus action actual affect age alcohol allergies/medications along also anatomi anoth answer any/medications/other aog appear applic approxim ask aspect assess attitud back base bear bewar blood brief build care career case cc center chang character chief chronolog classif clear client colleg communic complaint complet complic concis consid contraind contribut cours cover current data date day depend describ descript diagnosi diagnost differenti direct discharg discuss diseas dosag durat dx effect enabl entir environ essenti exam expect explan eye fact famili find first follow format forth frequenc general generic/trade genet give given go goal happen head health health-car help highlight histori home hpi ii iii ill import includ independ indic inform interpret intervent introduct iv ix jump keep knowledg laboratori languag learn like limit listen live lmp locat major manag manner marit medic mind name ncp negat new next normal note notepad nsg nurs observ occup one ongo onto open order outcom overview particular past patholog pathophysiolog patient pertin pharmacolog physic physiolog plan pmh present pressur problem procedur process progress provid puls purpose/objective qualiti question race rate rational read readi reason relev report respiratori respons result review ros rout scientif separ sever sex sexual short/brief side sign signific skill smoke social/work state statement status strong structure/s student substanc surgeri surgic system teach temperatur test theward tip toe treat treatment understand use v valu vi vii viii visit vital ward way well work written x xi xii xiii xiv xv xvi xvii