Reference no: EM133658969
Case: You are the triage tech at the Urgent Care Clinic. A young mother walked in with her 10-year-old daughter to be triaged.
She is limping. She says that she twisted her ankle when she was playing basketball with her team.
She is pale and breathing fast. She states that she is in a lot of pain.
She states that she is unable to stand on her own and cannot walk. She says she cannot move her foot up and down. She also states that he is having some numbness and tingling in the toes and feet. The area on the top of the foot nearest to the body is swollen, red, and bruised. She says she cannot move her toes.
You take her vital signs: heart rate is 100, breathing rate is 40 and blood pressure is 138/70
How would you chart this interaction? Using the SOAP format.
Think about how you would want to convey the information in this scenario to another health care provider, such as a nurse or a doctor, so that they understand the urgency of this health care issue and can prioritize whether it is emergent, urgent, or can wait. You are going to translate what you discover in talking to and looking at the patient into the medical terminology language and speak that language with colleagues and other health care professionals who are relying on you to be concise and accurate.
Your input may make the difference between good health care or delay of care. Your input will make the difference between a good outcome and a bad one.
Answer these questions at the end of your charting assignment.
Did you use a minimum of 4 medical terminology words for the system of study for that Chapter?
Did you use a minimum of 4 medical terminology words for the system of study appropriately?
Did you correctly spell all of the medical terminology words that you used?
Did you use correct spelling and grammar in writing your note?
Did your charting demonstrate mastery of the terms in this Chapter? How?