A 57-year-old male patient has fallen 20 feet while setting up holiday lights on his roof. He impacted the ground feet first and has suffered open fractures to both tibias, with both bones protruding through the skin. Your assessment reveals him to be responsive to painful stimuli. His airway is open, his breathing is rapid, and his radial pulse is weak. The skin is cool and diaphoretic. Vital signs are: pulse 132, respirations 24, and BP 106/90 mmHg. According to family, he has no medical history. Your partner is providing positive pressure ventilation. At this point in the patient's care, it is a priority for you to:
A) cover the patient with a blanket.
B) look for other injuries.
C) notify the hospital.
D) immobilize the fractures.
Question 2
Which of the following statements regarding documentation is CORRECT?
a. Patient refusals do not need to be documented except for the release-from-liability form signed by the patient.
b. Subjective statements, such as The patient was drunk, are appropriate.
c. Altering a patient care report is permissible if both you and your partner agree on the changes.
d. The patient report should be completed promptly after patient contact.
Diplacodes trivialis (male)
Nurse-patient interaction; nonveral communication
Building competency in patient centered care
Helping maintain accurate patient records is a critical part of the medical assistant's work.
Patient Teaching Methods Cont.
Patient with DiGeorge syndrome. Note low set ears and wide set downward slanting eyes; often these ...