Question

Mr. Hulchanski callls the physician's office and speaks with Becky Smith, the medical assistant. Mr. Hulchanski has had recent surgery and was instructed to call the office in one week to report how he is doing. Mr. Hulchanski reports that he is feeling fine and that the surgical incision looks like it is healing well. He says the only thing that he has noticed is that when he awakens in the morning, his pajamas and linens are soaked. Becky asks if he has been running a fever, and he states that he has routinely taken his temperature several times during the day and it has been normal. In fact, he states that he is sure he is not having a fever because he actually feels chilled at times. Becky states that she is glad to hear that he is doing so well and to call back if any problems develop.

1. Becky documents "patient reports he is doing well and will call back if any problems develop." Is this the correct note to make in the chart? Why or why not?

2. Did Mr. Hulchanski report any variances from the norm?

3. What could possibly be happening to Mr. Hulchanski?

Answer 1

1.Becky's way of documentation is not correct. As a medical assistant she has to document the phone call as every clinically relevant phone call must be documented. Becky should havr documented the following things:

* document the content of the patient's call on his record.

* it should include any specific problem , patient presented and specific instruction the health worker  given. In this case scenario Becky have not recorded the patient's problem of Night sweating. She could have write the problem in patient's own words.

* Date and time of phone call

* Name of the staff member, who received the call and sign below the document.

Becky documented that " patient is doing well" . She didn't write completely what the patient said. She also stated in document that patient told that will call back if any problems develop. But Becky is the one who asked the patient to call back if any problem develops, there also she documented wrongly.

2. Variances from the norm:

Mr. Hulchanski reports variations from normal. He reports about Night sweats. But as he is in post opertive period, His problem is not uncommon. Night sweats or excessive sweating ( Hyperhidrosis) are common in patients, who undergone a surgery recently.

3. Night sweats after surgery may be due to anaesthetic effects, infection, side effects of Medications, low blood sugar , healing process or it may be because of a case of Pulmonary embolism. As Mr. Hulchanski not reporting to any other discomfort, pain or  fever , the night sweating is probably because of Medication side effects or healing process/ inflammation.