Concept explainers
To discuss:
Can you identify essential information that must be documented in Mrs. P’s electronic record regarding her cardiac condition and treatment?
Case summary:
Mrs. P is a single, 88-year-old woman, was hospitalized for cardiac problems. She has been in her beginning of dementia. She lives alone in a small home along with her cats. When she was ordered for the discharge, the nursing student worried about Mrs. P’s ability to live safely on her own. The nursing student suggested her about moving to a retirement community or long-term care facility. But Mrs. P refused those options. The nursing student was worried about her safety and reported to the charge nurse. The charge nurse replied that we can do nothing if the patient is not willing to explore the other options.
To discuss:
Why is it important to document an assessment of the patient’s current mental health status?
Case summary:
Mrs. P is a single, 88-year-old woman, was hospitalized for cardiac problems. She has been in her beginning of dementia. She lives alone in a small home along with her cats. When she was ordered for the discharge, the nursing student worried about Mrs. P’s ability to live safely on her own. The nursing student suggested her about moving to a retirement community or long-term care facility. But Mrs. P refused those options. The nursing student was worried about her safety and reported to the charge nurse. The charge nurse replied that we can do nothing if the patient is not willing to explore the other options.
To discuss:
Can you identify any other essential information that supports safe patient care and that should be included in the electronic record?
Case summary:
Mrs. P is a single, 88-year-old woman, was hospitalized for cardiac problems. She has been in her beginning of dementia. She lives alone in a small home along with her cats. When she was ordered for the discharge, the nursing student worried about Mrs. P’s ability to live safely on her own. The nursing student suggested her about moving to a retirement community or long-term care facility. But Mrs. P refused those options. The nursing student was worried about her safety and reported to the charge nurse. The charge nurse replied that we can do nothing if the patient is not willing to explore the other options.
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