Chart Review #2:
Select a medical record from the Example Medical Records module (located at bottom of the Modules page) and review all documents within the record. Create a PowerPoint presentation with voiceover on each slide that guides viewers through the patient's chart. Submit your presentation as a PowerPoint file (do not convert to PDF as you will lose your voiceover).
Your PowerPoint must include at minimum:
- Chart ID (use file name – if this is missing, I will not grade and you will receive a zero for the entire review!!)
- A brief summary of the patient (demographics)
- History of present illness
- Information from progress notes (how did the patient's hospital stay go)
- Information from orders (what types of medications and other treatments were ordered)
- Description of treatment given, including therapy and/or (operative) procedures
- What did the pathology show if a specimen was removed?
- Was the patient discharged to home or another location?
- What was the final diagnosis?
Your voiceover must add substantial information beyond what is on the slides – do not read directly off the slides as you will lose points! If your presentation does not include voiceover, you will receive a zero!
- Face Sheet
- ER Record
- Discharge Summary
- H&P
- Progress Notes
- Orders
- Operative Report
- Pathology
- Medications
- Graph
- Nursing Assessment & Notes
- Discharge Assessment
,
- Face Sheet
- ER Record
- Discharge Summary
- H&P
- Progress Notes
- Orders
- EKG
- Medicaton
- Graph
- Nursing Assessment & Notes
- Discharge Instructions
,
- Face Sheet
- Discharge Summary
- H&P
- Consultation
- Progress Notes
- Orders
- EKG
- Lab
- Medication
- Nursing Assessment & Notes
,
- Clinical Resume
- H&P
- Consultation
- Progress Notes
- Orders
- Cardiac Cath
- Operative Report 1
- Operative Report 2
- EKG
- Radiology
- Laboratory
- Medication
- Nursing Assessment & Notes
- Discharge Instructions