Charting Patients
Charting Patients
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Charting Patients
Medical records require comprehensive descriptions to provide a detailed explanation to another medical practitioner about the condition of a patient (Barlow et al., 2019). Documenting that a patient has a rash is not sufficient in the medical world. Medical terms should describe various aspects of the rash. For instance, it is important to describe the condition of the rash such as the color, texture, and shape. A medical record should explain the condition using words like small, rounded, solid, red, and filled with fluid (Barlow et al., 2019). A healthcare worker should describe a rash in terms of what he or she can see. A rash that is filled with fluid will imply a different condition than a rash that is dry and clustered.
A practitioner carrying out a physical examination should engage a client to explain the cause of the rash, how long it has been there, whether it causes pain and itchiness or not (Barlow et al., 2019). The comprehensive description will trigger an idea of the diagnostic tests, the differential diagnosis, and treatment. For example, a painful rash will require the prescription of painkillers to relieve the pain. The information should indicate the location in the body parts. For instance, the disseminated gonococcal infection can lead to a rash in the face, scalp, limbs, and palms (Barlow et al., 2019).
Patients with rashes should indicate the possible causes of the rash. Rashes could be due to a bacterial infection, contact with an insect, or a recurring condition. The detailed information will help a practitioner to use the information for accurate diagnosis and treatment (Barlow et al., 2019). Documentation in the medical world should not use single words since it can mislead a practitioner prescribing medication. The information should be detailed to ensure another practitioner such as a nurse or pharmacist has the information on the cause of the condition.
References
Barlow, D. R., Pepper, A. L., & Torres, L. G. (2019). Skin deep: An assessment of New Zealand blue whale skin condition. Frontiers in Marine Science, 6, 757.
