Question

example of a full chief complaint explanation using the old chart method

Answer 1

Narrative charting is considered as the traditional method of charting patient data. In this methods the client's complaints,interventions and response are narrated in paragraphs in chronological order. This was widely used before introduction of flow sheet method and computerized documentation.Narrative charting is considered as a flexible method but it is time consuming and lacks subjectivity. Narrative charting also do not reflect the nursing process.

Example: Mr. Johnes,50year old male, was brought to the ER of Winter Hills Hospital by his wife on dd/mm/yy with complaints of sudden onset of slurring of speech with facial drooping to the left side. He have difficulty breathing from yesterday.. He experienced weakness of left side upper and lower limbs since 2 days. He had an incidence of fall from chair one day back and from then he compliants of pain on the lower back and right shoulder and reports 6/10 on pain scale of 0 to 10.

This can also be written as

Presenting Complaints/ Chief compliants:

Mr.Johnes 50year old male, was brought to the ER of Winter Hills Hospital by his wife on dd/mm/yy with complaints of sudden onset of slurring of speech and facial drooping to the left side

Difficulty breathing x 1 day

Weakness of left side upper and lower limbs x 2 days

Low back pain x 2 days .Pain score 6/10.

Pain right shoulder x 2 days, 6/10

Past Medical history

Mr.Johnes is a known case of Type II DM diagnosed 4 years back and hypertension diagnosed 3 years ago.

OR

Type II Diabetes Mellitus Dx 4 years ago

Grade I Hypertension Dx 3 years ago.

Medication history

Tab. Glimepiride 2mg, twice a day

Acute hospital assessment findings:

Vital signs: temperature: 98.6⁰ F, Pulse: 82, Respiration: 22 breaths/min, BP:148/90mmhg, SPO₂ : 94%, Pain 6/10

Physical examination: confused

left side facial droop

slurred speech

Left side motor weakness: upper limb-0/5 and lower limb 2/5

Decreased tone

Mild left side neglect present

Stroke scale score on admission :19

Lab findings:

INR - 1.2

CT - Provisional diagnosis - Acute ischemic stroke

Patient treated with tPA in 1 hr 15 minutes after symptom onset

Medical Management:

Thrombolysis with tPA

Watch for complications

24 hour monitoring