Question

Read the following scenario and then practice writing a POMR progress note and a focus charting note using the data given.

Marvin Barnes was admitted with the medical diagnosis of pneumonia. He has symptoms of problems with oxygenation because of his excessive pulmonary secretions. When you go to assess him, you discover that his temperature is 102.6°F (39.2°C); pulse 112 beats/min; respirations 26 breaths/min and shallow; and blood pressure 147/92 mmHg. He is coughing and produces yellow-green sputum. He is having difficulty stopping the cough. He has oxygen via nasal cannula running at 3 L/min. He has acetaminophen ordered for fever over 100.2°F (37.9°C). You tell him that you will be back with medicine for his fever and that you will call the primary care provider for an order for some cough medicine to relieve the cough.

Answer 1

POMR progress notes include history, physical examination, laboratory investigations, initial plan,progress notes,and follow up notes.In this scenario,it would be,

Mr.Marvin Barnes,got admitted with the diagnosis of pneumonia.He has symptoms such as excessive yellow coloured sputum, cough,temperature 102.6°F , pulse 112/mt, respiration 26/mt,and blood pressure 147/92 mm of Hg.He is on oxygen 3 l/min via nasal cannula.Initially, acetaminophen ordered for fever .Cough medicine to be prescribed and oxygenation to be maintained.