Medical Chart Data Retrieval Worksheet: Cases 06 and 10 Evaluation

This assignment presents a detailed medical chart data retrieval worksheet, focusing on Cases 06 and 10. The worksheet requires the student to extract and analyze critical information from the provided medical records, adhering to specific guidelines. The student, Aisha, is tasked with identifying key data elements across various sections of the medical chart, including face sheets, history and physical reports, progress notes, and physician's orders. The analysis includes assessing the completeness and accuracy of documentation, calculating length of stay, identifying diagnoses, and evaluating the presence of necessary consents and directives. The assignment also requires an assessment of the completeness and compliance of physician orders, including timing, signatures, and corresponding reports. The assignment utilizes guidelines from Shanholtzer, Chapter 6 and web-based resources to ensure a thorough analysis. The student is also required to identify any documentation issues and non-compliance with established guidelines. This exercise aims to enhance the student's ability to interpret medical documentation and apply chart analysis principles.

MEDICINE CHART
DATA RETRIEVAL WORKSHEET CASE 06
DATA ELEMENT ANSWER
Student’s Name AISHA
Patient Name Charles Benson
Case Name/Number Case 06
Face Sheet /Admitting Information
Medical Record Number Case 06
Admission Date/ Discharge Date/LOS Admit 04-24-yyyy, discharge 04-29-yyyy, LOS-5 days
Attending Physician Donald Thompson, MD
Admission Service and Type ICU, Type 2
Admitting Diagnosis Chest Pain
Principal Diagnosis Costochondrtitis
All Consents and Advance Directives completed and
signed
Consent to Admission, consent to Release Information, and
advanced directives signed by patient
History and Physical/Consultation- Completed within
24 hours of admission or within 30 days prior to
admission?
Dictated by physician on day of admission 04-24, typed on 04-
29
1. What was the chief complaint? Chest pain into left lateral chest wall accompanied by shortness
of breath and nausea
2. List the details of the present illness Patient in gross distress and suffering from severe chest pain
3. List briefly relevant social and family history Married, no longer a smoker and without any family history of
any particular kind of disease. Although, he was exposed to
direct radiation during blasts, while he had served for the WWII.
He was also in direct contact with wood dust due to his
profession of being a cabinetmaker.
4. What is included in the review of the systems? noncontributory
5. What are the patient’s vital signs? Blood Pressure- 140/100, Temperature- 98, Pulse- 68,

Respirations- 16,
6. What abnormal findings are included in the
physical? Chest pain probably in the chest wall. ASCVD with history
of infarction and CVA’s
7. What is the provisional diagnosis? Chest pain with unstable angina.
8. What is the plan? Get the patient admitted to the hospital, put the patient on
NSAIDs and check for any kind of cardiac involvement.
Progress Notes
What disciplines have written in the progress notes? Physician , Inflammation Treatment, Nursing
What type of information is included in the non-
physician notes?
No verbal orders- all the orders are written and signed by the
physician.
Are the progress notes legible? Are the documentation
problem or issues mentioned in the progress notes?
Legible but o note was signed on one of the progress notes.
Physicians Orders
Is each order timed, signed and dated? No time mentioned on the admit order.
Is each telephone and verbal order signed by the
physician?
No mention of any kind of verbal orders written and signed by
the physician been given to the patient.
Look at the first day’s admission orders. What type of
services and medications were ordered?
Diet including protein, Proventil treatment, via aerochamber,
Inflammaion treatment, 2 puffs of Proventil, Medication
included ( diltiazem, Lasix, Isossorbide),
Is there a corresponding report for each laboratory
test, x-ray or procedure ordered? List exceptions.
All the mentioned are present.

MEDICINE CHART
DATA RETRIEVAL WORKSHEET CASE 10
DATA ELEMENT ANSWER
Student’s Name AISHA
Patient Name Paula P. Paulson
Case Name/Number Case 10
Face Sheet /Admitting Information
Medical Record Number Case 10
Admission Date/ Discharge Date/LOS Admit 04-26-yyyy, discharge 05-01-yyyy, LOS- 5 days
Attending Physician Donald Thompson, MD
Admission Service and Type Medical, Type 2
Admitting Diagnosis Chest Pain
Principal Diagnosis Acute Bronchitis
All Consents and Advance Directives completed
and signed
Consent to Admission, consent to Release Information, and
advanced directives signed by patient
History and Physical/Consultation- Completed
within 24 hours of admission or within 30 days
prior to admission?
Dictated by physician on day of admission 04-24, typed on 05-
01
1. What was the chief complaint? Shortness of breath
2. List the details of the present illness Green sputum and wheezing breath and extreme shortness of
breath
3. List briefly relevant social and family history No family history had been provided
4. What is included in the review of the
systems?
none

5. What are the patient’s vital signs? None mentioned in the medical records
6. What abnormal findings are included in the
physical? None mentioned
7. What is the provisional diagnosis? Severe Reactive airway disease accompanied by metabolic
acidosis
8. What is the plan? Iv steroids, Proventil treatment, O2 stats
Progress Notes
What disciplines have written in the progress
notes?
Physician , Proventil treatment, ventilation, Nursing
What type of information is included in the non-
physician notes?
No verbal orders- all the orders are written and signed by the
physician.
Are the progress notes legible? Are the
documentation problem or issues mentioned in the
progress notes?
Legible and all the notes was signed on one of the progress
notes.
Physicians Orders
Is each order timed, signed and dated? Yes, time mentioned on the admit order.
Is each telephone and verbal order signed by the
physician?
No mention of any kind of verbal orders written and signed by
the physician been given to the patient.
Look at the first day’s admission orders. What type
of services and medications were ordered?
Regular diet, Albuterol treatment, Solumedrol, Medication
included ( Aminophylin, Tylenol, O2 stats),
Is there a corresponding report for each
laboratory test, x-ray or procedure ordered?
List exceptions.
All the mentioned are present.