is this a correct admitting diagnosis?

[onlyj]

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-arthroplasty

history 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]

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]

"r/t" usually means "related to" not "right" ... would just spell out the word "right" when describing which knee it is.

[NRSKarenRN, BSN, RN]

moved to our: nursing student assistance forum