Creating a Medical Chart
Student worksheet
Introduction
Medical charts play an important role in patient care. A complete medical chart allows the physician and other medical personnel not only to review the patient’s immediate health care issues, but also to review patient history, past doctor and hospital visits, and other important information such as allergies and medications. This type of information is vital to providing good health care.
Medical charts may differ slightly depending on the medical specialty (for example, cardiology (the study of the heart and its diseases) vs podiatry (the study of the human foot) and the preferences of the medical personnel using them. The record usually contains complete information as needed for the health care specialty.
Students participating in the CyberSurgeons mission use fictional patients’ medical charts to diagnose conditions. This activity allows you to become more familiar with the components of charts and to realize how integral charts are to effective patient treatment.
Note: During the CyberSurgeons mission, the medical charts are in an abbreviated form allowing you to access all information necessary for diagnosis and treatment recommendations, but eliminating the necessity for reading long sections of text. Please remember this is a modification of a chart and does not reflect the content of a complete medical chart.
Purpose
To become familiar with the components of medical charts in order to understand how they are used in providing good health care.
Objectives
You will:
• Create a medical chart and case study for a fictional patient. • Recognize the symptoms of alcohol poisoning. • Diagnose and suggest treatments • Develop a prognosis for the fictional patient. • Discuss the case in a case study review session as the student residents discuss their patients.Materials
Computer with internet for research
Printer
Vocabulary
allergy—an abnormal reaction, such as itchy eyes, runny nose, rashes, or wheezing, of the body to a foreign substance.
medication—a substance or drug used to treat a disease or condition
chief complaint—the problem that brought the patient in to see the doctor
demographics—information about a patient that is not strictly medical. Types of demographic information that may be collected include patient address, contact numbers, emergency contacts, race, religious preference, and occupational information.
diagnosis—the identification of a disease by symptoms and clinical test results
differential diagnosis—another possible diagnosis of a disease or condition that may be likely in addition to others that may have similar symptoms.
family history—the health history of immediate family members including diseases or conditions and causes of death. Family history is a valuable tool in helping to diagnosis diseases and to providing complete health care.
habits—routines or practices that may impact the health of a patient, including use of tobacco, alcohol, or illegal drugs, exercise, and/or diet.
initial diagnosis—the first diagnosis made after considering the chief complaint, the family history, and other relevant information such as allergies, medications, or lifestyle habits.
medical history—a health history of the patient including diseases and illnesses (may include surgical history on some medical charts).
physical examination—an examination of the physical condition of the patient, including a record of vital signs, palpitation of internal organs and glands, and observation of skin, eye, ear, nose and throat conditions.
prognosis—an estimation of survival and recovery from a disease as expected from the usual course of treatment and patient status
surgical history—a record of surgeries performed for the patient, including dates and type of surgery, surgical details, and post-operative recovery information.
test orders—orders for clinical tests to be performed for diagnosis or patient health evaluation.
vital signs—patient measurements of temperature, heart rate (pulse), blood pressure, and respiratory rate.
Components of a medical chart
Demographics
Chief complaint
Medical history
Habits
Family History
Medicines
Allergies
Physical Exam
Tests ordered
Initial diagnosis
Differential diagnosis
Test results
Final diagnosis
Treatment
Recommendations
Prognosis
Task
Write a complete medical chart for a patient who has alcohol poisoning.
- Include all the components of a medical chart listed above.
- Create the details for the components that do not require a specific and accurate set of facts; use accurate information for the symptoms the patient would be experiencing.
- Use accepted protocol for recording a medical chart. In the United States, all written patient records must include dates of treatment written in pen. Errors should be corrected by drawing a single line through the mistake, initializing the line, and writing the comment correctly.
Extensions
Students may research the incidence of their assigned condition or disease. They should include statistics on occurrence and statistics on the population in which it is most prevalent.
Medical Chart
Name Nick Morris Age 17 Gender M
Date _______________
Chief complaint Patient is carried into the ER by several friends. They say he passed out during a party and they don’t know what’s wrong with him. They are not sure how__ long he has been unconscious. They were asked if he had been drinking, and they say that he has not been drinking all night. He just passed out._______________________
One friend says he seemed confused at one point.______________________________
Medical history _________________________________________________________
___________________________________________________________________________________________________
Habits (tobacco, alcohol)
___________________________________________________________________________________________________
Family history ___________________________________________________________________________________________________
___________________________________________________________________________________________________
Surgical history ___________________________________________________________________________________________________
___________________________________________________________________________________________________
Medications ___________________________________________________________________________________________________
Allergies ___________________________________________________________________________________________________
Physical Exam ___________________________________________________________________________________________________
Initial Diagnosis ________________________________________________________
Differential diagnosis (if any) _____________________________________________
Tests ordered ____________________________________________________________________________________________________
____________________________________________________________________________________________________
Test results ___________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Final diagnosis _________________________________________________________
Recommended Treatment ____________________________________________________________________________________________________
____________________________________________________________________________________________________
Prognosis ____________________________________________________________________________________________________
Discussion Questions
1. How does a medical chart help diagnosis and treatment?
2. How might incomplete information on a medical chart cause a misdiagnosis of the problem or condition or delay treatment that could be life-saving?
For example, Nick’s friends did not admit that he had been drinking when they brought him to the Emergency Room. How did this affect his care?
3. Why can’t we do more scientific research and experimentation to more closely define the lethal dose of alcohol poisoning?
