How to "pick" dx info to gather from Chart?

  1. We go the night before we see patients. We have a list of all sorts of things we need to collect. (Seeing Geriatric patients for our first set).

    We have to do a careplan for each patient, weekly (we start with 1 patient). In that careplan we retrieve 3 dx from the charts, of that we use 1 dx to form our weekly careplan. Our comprehensive one covers more dx.

    So, my question is anyone have suggestions on what dx to grab from the charts that would be a great learning experience for careplan learning. The instructor explained that many geriatric patients can have several medical dx at one time and to start we are only going to focus on a few, til we get the hang of it. I am not looking for the easiest, just ones that would "teach me" a lot about the nursing process.

    Thanks in advance.

    P.S. Instructor says to pick the "Big dx" (DJD, CVA) and left it at that. I am a NEW nursing student and telling me Big dx is like telling me to go pick stars from the sky, LOL (Completely foreign)
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    About nurz2be

    Joined: Aug '07; Posts: 864; Likes: 773
    Nursing Student

    5 Comments

  3. by   UM Review RN
    These are some geriatric "biggies" (in no particular order):

    CHF (Congestive Heart Failure), CAP (Community Acquired Pneumonia), AMI (Acute Myocardial Infarction), Stroke, Sepsis.
  4. by   Daytonite
    The most common medical diagnoses that people end up hospitalized for in nursing homes are strokes, TIAs, dementia, Alzheimer's disease, COPD, other lung diseases, CAD (coronary artery disease), other heart diseases such as congestive heart failure, hypertension, various kinds of GI problems, and failure to thrive (not eating enough to keep up their weight). I would also look at the medications they are getting as this will tell you what diseases the doctor is aiming treatment at.
  5. by   nurz2be
    Thank you ladies immensely. We got to look over some charts today and I was rather disconcerted by a few things.

    1 chart had a NKDA Allergy sticker on the outside. I opened it the the initial physician assessment to see it say in rather large font, ALLERGY TO ANTI-INFLAMMATORY MEDICATIONS..... my jaw dropped, I told the instructor.

    Another girl in class had a DNR sticker, actually 2, on the outside of her chart only to find on the inside, no "legal" documentation to back that up.

    Does this seriously occur often?????
  6. by   Daytonite
    It's not supposed to, but it can. When I worked in long term care, I spent a lot of time clearing up those kinds of discrepancies in the charts. If no one takes the time to do it then you will find that happening.
  7. by   richardjboro1
    you can scan quickly the entire chart, but spend most of your time with: Labs, health and physical, and tests. You can also quickly scan the progress notes, then the doctor's orders. If you have one patient, you can be done in less than 30 min (that is, if you can read the notes, and quickly write the info you need).

    Hope that helps somewhat.

    Richard

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