Handover and written nursing report

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Reference no: EM132088715 , Length: word count:220

Handover and Written Nursing Report

Mr Jason Bilko is an 81 year old male (MRN: 12-34-56, DOB: 01/01/1937) who lives as 1 Soft Street, Chowtown, 4560. He presents to the emergency department on the 03/09/2018 at 1600hrs with chest pain and shortness of breath.

He has had prior admissions to the hospital with Unstable Angina and has a history of multiple falls recently. On arrival, patient denies chest pain but has a resp rate of 32 and a SaO2 of 82% on room air. After you receive handover from the ambulance officers, you do an assessment on Mr. Bilko. You notice that his heart rate is 101bpm, SaO2 88%, BP 138/72, temp of 36.8 and Resp rate of 28.

You document these in his observation chart and commence 6L 02 via a Hudson mask. You complete an ECG and attach the patient to a cardiac monitor-monitoring in sinus rhythm. The ED staff specialist, Dr Lance, reviews the patient and orders a chest x-ray. He reviews the ECG and notes no abnormalities. He inserts an IV cannula and takes blood. He orders IV fluids which you commence.

The patient returns from radiology and Dr Lance diagnosis the patient with mild pulmonary oedema and admits him under Dr Turner. He orders Furosemide 40mg IV which you administer. After you administer the medication, you repeat the observations and document them in the observation chart.

Written Nursing Report

Complete all the required details for your patient in the progress notes attached.

Attachment:- Template.rar

Reference no: EM132088715

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Reviews

len2088715

8/17/2018 10:09:03 PM

Criteria 6 - Content of the report Ifachangeinthepatient/client’sstatushas been reported to the responsible medical practitioner, the name of the medical practitioner andthe date andtime that the change was reported to him / her is documented. If a change in the patient / client’s status has been reported to the responsible medical practitioner, documentation of the nameof the medical practitioner and the date and time that the change was reportedtohim/ herhasnot been documented. Criteria 7 - Content of the report Notes were written at the time of an event or as soon as possible afterwards (contemporaneously). The timeof writing must be distinguished from the time of an incident, event or observation being reported. Noteswerenotwrittenatthetimeofanevent or as soon as possible afterwards (contemporaneously). The time of writing not distinguishedfromthetime ofanincident, event or observation being reported. Criteria 8 - Content of the report Entries are sequential - where lines are left between entries they must be ruled across to indicate they are not left for later entries and to reflect the sequential and contemporaneous nature of all entries.

len2088715

8/17/2018 10:08:44 PM

Criteria 3 - Legal requirements Date of entry (using ddmmyy or ddmmyyyy). Time of entry using a 24-hour clock. Date of entry not provided or provided incorrectly. Timenotprovidedusinga 24-hour clock Criteria 4 - Legal requirements Documentation signed by the author, including signature, printed name and designation. Documentationis not signed as per criteria including signature, printed name and designation. Criteria 5 - Content of the report Care / treatment plan, including risk assessments with associated interventions are documented. Care/treatment plan, including risk assessments with associated interventions are not documented.

len2088715

8/17/2018 10:08:37 PM

Criteria Satisfactory Unsatisfactory Criteria 1 The report is within the 200-word count. The report exceeds the word count. Criteria 2 Documentation is clear and concise. Documentationislegible. Documentationisin English. Documentation uses appropriate vocabulary, spelling andgrammar. Documentation is not clear or concise. Documentationis notlegible. Documentation is not in English. Documentation does not use appropriate vocabulary, spelling andgrammar.

len2088715

8/17/2018 10:08:24 PM

Criteria 9 – Content of the recording Handover presented in a professional manner and student is wearing uniform. Student is not in uniform and elements of the verbal handover are not presented professionally. Criteria 10 – Content of the recording Video recording is filmed in one continuous shot and has not been edited. Video recording has not been filmed in one continuous shot and has been edited.

len2088715

8/17/2018 10:08:18 PM

Criteria 5 – Situation State the immediate clinical situation of the patient. Does not state the immediate clinical situation of the patient. Criteria 6 – Background Provide relevant background/history to the patient’s clinical situation. Does not provide relevant background/history to the patient’s clinical situation. Criteria 7 – Assessment List the most important and recent observations. Does not list the most important and recent observations. Criteria 8 - Recommendation Identify assessments and actions that need to occur. Does not identify assessments and actions that need to occur.

len2088715

8/17/2018 10:08:01 PM

401020 Professional Practice 6 Marking Criteria: Verbal Handover Criteria Satisfactory Unsatisfactory Criteria 1 – Length and clarity of the audio recording Video recording is uploaded by the due date. No submission of the video recording by the due date. Criteria 2 – Length and clarity of the audio recording Recording is within 5-minute limit. Recording exceeds the five (5) minute time limit. Criteria 3 – Length and clarity of the audio recording The recording can be heard in its entirety. The recording cannot be heard in its entirety. Criteria 4 – Introduction Clearly identify the patient and your role. Does not clearly identify patient or your role

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