i'm only in my first level and i need to fill out subjective/objective factors.it says admitting diagnosis, history of present illness, past medical history, etc. this is what i put and i wanted to know if it sounded correct. a patient had a r/t knee replacement surgery for the 2nd time due to an infection that he got for the 1st one. and according to his info, his prosthesis was removed due to the infection and he was on vancomycin for 6 weeks. so he came into the hospital for the surgery.admitting diagnosis: r/t total knee re-arthroplastyhistory of present illness: pt had right tka 2008, cabgx3 2010, mrsa spine 9/2010; r/t knee became infected and had to have r/t knee prosthesis removed, was treated with 6 weeks vancomycin. needs revision of r/t tka does this sound correct? i also have to do a care plan, but that is after.
NPinWCH 374 Posts Specializes in Family NP, OB Nursing. Has 15 years experience. Apr 3, 2011 The cabg and mrsa of spine should be past medical history. History of present illness should only be what is pertinent to his current admission.
coast2coast 379 Posts Apr 3, 2011 "r/t" usually means "related to" not "right" ... would just spell out the word "right" when describing which knee it is.
Home Health Columnist / Guide NRSKarenRN, BSN, RN 11 Articles; 17,846 Posts Specializes in Vents, Telemetry, Home Care, Home infusion. Has 46 years experience. Apr 3, 2011 moved to our: nursing student assistance forum
