Professional Documents
Culture Documents
English 2010
Semester Project
Part One
Intro
important thing in the medical field. Everyone working in the medical field
medical charting. Such as, it will help doctors to prove that the treatment
was carried out properly, helping analyze the treatment results, plan
treatment protocols and many more. Every person working in the medical
field will have documented everything they do for the patient in the
computer.
Purpose
what the care has been given, giving, or need to give. There is a saying if
and lot of incidents happens. Doctors are able to save many peoples but not
everyone. When that happens family member might deny that and blame
the doctors. I am not saying that doctors dont make mistakes. All I am
saying is, if they didnt make a mistake and the treatment went as it is
supposing to be, it will be the legal documentation that will save the doctors
carrier and life. If you charted the wrong thing and the nurse happen to give
the wrong dosage of medicine, you just put the patient life in danger or even
kill them. A simple mistake in medical field can take someones life.
anytime when we need and even able to look at the history of patient. Every
time doctor do any kind of treatment, they will look at your medical history.
Not only yours but your family history also because lot of genetic disease has
Context:
Patient identification
Physical examination
Treatment that is given and are still in process.
To teach client.
Discharge plan and process after that.
Operative procedures.
Evidence of nurse care or treatment.
Medical history and medical diagnosis.
Writer/Reader
Writer and reader are everyone who is working in the medical field.
For example: CNA, does most of the daily bases activates. They chart
everything they do into the computers with date and time. Once they do this,
nurse checks it. The nurse checks it whenever they get time. They check it
very often. In this case CNA is the writer and Nurse is the reader. Second part
comes the Nurse role. The most important part of nurse is they do procedure
call head to toe assessment. Nurse charts all the things and after that
doctors see it. Here, Nurse become the writer and Doctor becomes the
reader.
Conventions:
for profession. Formal, which means no bad words, correct spelling, clear to
is very important and which I came to know when I was taking CNA class in
high school. Anyone who goes into medical field are required to know the
medical abbreviation because if they dont know about it, then it will be very
time doctor, nurse, or CNA, leaves a note they will have medical abbreviation
in. It will take longer time to write all the words so they use short cut to
important to know that never use slang words in. It is not appropriate and
professor sent me. On those websites I had almost everything I need to know
about the nursing charting. There was why the nursing charting was done,
who the audience will be, and style. The only part I wasnt sure was, who
does what part? Everyone in medical field have their own responsibility from
CNA through Doctor. So, first I interview one of the CNA from the hospital I
work in. She works at the bone marrow transplant department. She said she
does most of the daily bases activities. Such as checking blood pressure,
respiration, heart rate, pain, weight, Temperature, oxygen, and bed sores.
They check the patients weight 3 to 4 times a day, depending on the patient.
As soon as they are free or they are done with the daily bases activities, they
charted it immediately. If the CNA sees abnormal while doing vitals, they
nurses also do the intake and output fluid, patient response to the medicine,
and paint. Most important thing they do is head to toe assessment. The
picture I posted below shows the head to toe assessment. She said that
they chart all these things and after that doctors see it. If the nurse sees
anything abnormal, they directly go and talk to doctor. They chart everything
but most of the time they dont wait for doctor to see it. They will just go up
prescripts the medicine. Not even Nurse have the authority to prescripts any
kind of medicine to patients. Nurses only gives the medicine that has been
prescript by doctor. She also said that they chart all the medication they
give. They also chart PRN, which means as per needed medication such as
nausea, pain, also the response to the medicine also. They ask questions of
what kind of pain are they in or ask to describe their pain. Did the pain come
quickly or slow, or where the pain is and if it radiates it anywhere? They also
Reference
Part 3
vitals.
Date: 12/12/12
Name: Aggarwal Kajal N/A
Last Frist Middle
Patients:
CNA
Vitals: Normal Vitals:
o Blood pressure: 140/98 90/60 to 120/80
o Pulse rate: 80/120 60/100
o Respiration:20/26 12/18
o Pain: 9/10
o Weight: 90 pound Depends on the age and
height
o Temperature: 105F 98.6 F
o Oxygen: 102 millimeter of mercury
o Sores: sores everywhere
o Vomiting: 3 times with in 1 hour
Purpose:
can compare the vitals from the previous time and see how much good or
worse has the health been. Through the vitals we can also see what
medicines does the patient need to take and take care of diet also. Since the
patient have low weight, dietitian will give more nutritional and protein food.
This will also help doctor prescript medicine for patient or show nurse what
Writer/reader
The first step to medical field is CNA so I will be taking these vitals as a
CNA. The vitals that I took was very abnormal and that is very unusual to
have. The nurse will see it once I document that in the computer. I am the
writer and the nurse is the reader. Sometimes there comes a point were you
need to talk to nurse rather than communicate through computer just like in
this case. The patient needs and immediate treatment. So, I will be going up
to nurse and telling her about the patient situation. I will be the speaker and
Convention:
unwell. Need immediate care. BP high. In high of pain. Low Weight. High
It will be written short but very clearly. Short because doctors and
nurses are very busy taking care of the patient and they dont have so much
time to read a long long thing that can be explain in two words. Clear
because what is the use of it if the doctors cant read what you have written.