Unit 5 Assignment Worksheet
Unit outcomes addressed in this Assignment:
ED/ PROVIDER NOTE
PCP: Medical Center
Date of Arrival: 4/12/2014
Diagnosis: L AOM. Patient is very well-appearing and well-hydrated with no evidence of meningitis,
mastoiditis, pneumonia, or other SBI.
Disposition and Plan of Care:
-Amoxicillin 620 mg PO BID x 10 days
-Follow-up and return precautions as per ACI
History of Present Illness: Source: Mother and sister
CC: RN, congestion, and ear pain
History of Present Illness: is a previously healthy 23 month old with tactile fever x 2 days with
ear pain since 0300 this morning. +RN and congestion for the past two days. Taking less PO than usual,
but urinating normally. No vomiting or diarrhea. No other concerns.
Past Medical History:
No prior hospitalizations
No prior surgeries
No ongoing medical conditions
Negative for chronic childhood conditions
Lives with parents and siblings
Allergies: No Known Allergies
Immunizations Status: up to date
HEENT: RN, congestion, ear pain
Central Nervous: negative
Pulse 158 [crying] | Temp 98.2 | Resp 30 | Wt 15.3 kg, is alert, well developed, well nourished, in no acute distress
HEAD: normocephalic and atraumatic
EYES: pupils equal, round and reactive to light and extra-ocular movements intact
EARS: R TM is normal appearing. L TM bulging and erythematous with purulent effusion
NOSE: no discharge
OROPHARYNX: mucous membranes moist with no oral lesions
NECK: neck is supple with full active range of motion and no adenopathy
CHEST: clear to auscultation bilaterally and no wheezes, rales, or rhonchi
CARDIAC: regular rhythm, no murmurs and normal S1 and S2, no gallop
ABDOMEN: nondistended, soft, nontender to palpation , no hepatosplenomegaly, no masses, no guarding
or rebound tenderness and normoactive bowel sounds
BACK: exam deferred
GU: exam deferred
EXTREMITIES: brisk capillary refill and no edema
SKIN: no rashes and no petechiae
Your assignment should have no more than 10% quoting. Please use paraphrasing, in-text citation, and a list of references, as appropriate.
Your assignment should:
Unit 5 Assignment Chart Review & Physician Query
Chart reviewed: #ED322223
1. Describe the deficiency that was present in the health record and would require a physician query to resolve:
2. Compose a query to the physician to resolve the deficiency:
Unit 5 Assignment Grading Rubric:
|Assignment Requirements||Points possible||Points earned|
|Part 1: Student has demonstrated the ability to identify deficiencies within the health record.||0–10|
|Part 2: Student has demonstrated professional communication through the composition of a physician query.||0–10|
|Total (Sum of all points)|
|Points deducted for spelling, grammar, and/or APA errors (Max 10%)|
|Adjusted total points|
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