Write a narrative note about your patient. Include your assessment information, lab and diagnostic results, treatments and the patient’s response to treatment, developmental cognitive level assessment. Organize your note as if you were giving report to the next person who will be caring for this patient. Include everything that person needs to know to maintain continuity and be able to give safe care. This should be written in paragraph form, in full complete sentences. Abbreviations should NOT be used. Be sure to include cognitive and physical development.
Write a narrative note about your patient. Include your assessment information, lab and diagnostic results, treatments and the patient’s response to treatment, developmental cognitive level assessment. Organize your note as if you were giving report to the next person who will be caring for this patient. Include everything that person needs to know to maintain continuity and be able to give safe care. This should be written in paragraph form, in full complete sentences. Abbreviations should NOT be used. Be sure to include cognitive and physical development.
Admission date: 11/12/2017 Emergency Room
Client age/gender:11 year old boy
Reason for visit: Right foot pain
Allergies: no known allergies
Background Information:The patient states that he was playing in his back yard when he tried to do a handstand and fell and injured his ankle yesterday (11/11/2017). Today he was brought to the emergency department by his parents for complaints of right ankle pain. Patient denies any headaches, loss of consciousness, and any other symptoms at this time that suggests head injury. Bruising and swelling were observed on the right lower extremity.
General Assessment: no apparent distress. Patient is awake, alert and oriented. Skin warm and dry with good turgor and normal texture. Soft tissue edema on the right foot. Has full range of motion and muscle strength in all the other extremities. Ecchymosis in right lower extremity
Labs: No lab workup were done on this patient. (this is important to add)
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