Research the disease identified to supplement the information documented in the health record.

Instructions

    1. Read the health record to identify the patient’s diagnosis and trace the course of treatment. Download the following heath record to begin this assignment:

      Patient Medical Record

Report the following information from the health record:

    1. Health Record #
    2. Diagnosis
    3. Related History
    4. Physical Findings
    5. Lab/X-Ray Findings
    6. Course of Treatment–including medications administered
    7. Condition on Discharge
  1. Research the disease identified to supplement the information documented in the health record. Do not use your text, you must use a valid health resource such as the Merck Manual or the NIH (National Institutes of Health):
    1. Pathology of the disease
    2. Symptoms and signs
    3. Laboratory findings
    4. Diagnosis
    5. Prognosis
    6. Treatment alternatives
  2. Write 2-3 paragraphs comparing what you found in the health record to what you found in the references. You must state whether or not you feel the disease was treated appropriately in the hospital based on what you found in step #2.
  3. Include a Reference page in APA format. The patient chart does not need to be included on the reference page. For more information on APA, navigate to the Resources tab in this course.

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