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Problems in EHR: Name: J. M Age: 65 Y Allergies: NKDA Full Code -…
Problems in EHR:
Name: J. M
Age: 65 Y
Allergies: NKDA
Full Code
1: No documented head to toe assessment
Patient suffers from CHF and it is important to have baseline to determine worsening or improvements In findings
CHF can cause edema and Its important to determine if there was any signs of fluid retention to begin with
There was no noted Injection site evaluation for blood thinner
2: Vital Signs only charted once
Patient's initial vitals show
elevated blood pressure
reading,
elevated heart rate
and
low O2 levels
It becomes difficult to administer medications if vital signs are not recorded
Blood pressure medication can cause a drop in BP aif it stabilized before
Once medication administration Is completed, vitals must be taken to see Improvement In baseline vital signs
3: Incomplete charting
There was no charted pain reporting whether It is a 0/10 or 10/10
There was no charted lab CBC
WBC would confirm Infection and safe to use the antibiotics
There was no lab/imaging done to determine respiratory Infection
Patient Is taking antibioitics and that can cause complications
Destroys good flora In the intestines
Can cause diarrhea
C-diff result of excessive use of antibiotics
in vitals there is Incomplete Information regarding oxygen source
its important to have this Information because the patient has low levels of O2.
There are numerous of pending active orders that have not been completed s