Question

29. 
    Bedside Assessment and Electronic Health Recording

Compare and contrast “Paper Charts” versus “Electronic Medical Records”

The Pregnant Woman

Discuss the trimesters in pregnancy and point out the important developmental steps

Functional Assessment of the Older Adult

Discuss the techniques and assessment of an adult’s IADLs

Answer 1

Q1

Compare and contrast paper charts versus electronic medical records

The difference between the paper chart and the electronic medical records is that Paper charts are the recording of the patient information in the paper and recorded manually. There is a need to write with proper handwriting and should prevent overwriting. For electronic medical records, the patient information is recorded in the computer of the information system. There is no need for good handwriting and it is more secure than the paper chart, as a password or only an authorized person can see the information on the computer.

The contrast is that both the paper chart and electronic medical records are used in hospitals for the record of information for the patient or record for the patient's data.

Q 2

Trimester of pregnancy

There are three trimesters of pregnancy

- 1st trimester

It is from 1 month to 3 months. In this, fertilization occurs, there is the formation of the embryo, by 4 weeks nervous system, heart, arms, legs. At 8 weeks of facial structure like eyes, nose face, mouth start formation, all major organ start formation, heartbeat started, elongated legs, and arms leads to the formation of fingers and toes. The umbilical cord is clearly seen. At the end of the 12 weeks, the nervous system and the muscles begin to work together, able to identify the sex organ, head growth slow down.

- 2nd trimester

It is from 4 to 6 months. At 16 weeks, The musculoskeletal system continues to form. skins begin to form. there is the development of meconium in the intestine. The fetus begin sucking motion of the mouth. At 20 weeks, the fetus become more active. There is a start formation of lanugo and vernix to cover all over the skin. The eyelashes, eyebrow, fingernails are formed. The fetus can hear and swallow. At 24 weeks, there is the development of bone marrow to begin the formation of RBC, taste bud formation occurs, fingerprint and footprint are formed. The lungs are formed but not yet functioned, the formation of the uterus ovaries for girl fetus and testis start descent for boy fetus.

- 3rd trimester

It is from 7 to 9 months. At 32 weeks the bone of the fetus is developing well but still soft. There is a kicking movement started, the eyes can open and closed, the fetus's body starts to store the vital minerals, the lanugo starts to fall off. At 36 weeks the vernix becomes thicker, body fat increase, At 37 to to 40 weeks, the fetus is full-term and the head turn down for birth.

Q 3

Answer: IADLs for assessment of adult means the instrumental activities of daily living. It is associate with the independent services that are required to form maintaining independent living.  Assessment includes

- companionship and mental support: This included assessment of the needs of the patient to support to keep a positive frame of mind.

- Transportation and shopping: Assess how much a person can go for shopping and go to grocery and pharmacy without help.

- Preparing meals: Assessing the individual for fulfilling the planning and preparing the meals for self without help.

-Managing a person's household: assess how much a person can do a household without help include cleaning, tidiness, removing the trash, doing laundry, folding clothes.

- Managing medications: Assess how much a person need in getting the prescribed medication, fill the medication on time and taking the medication on time

- Communication with others: Assess how much a person can communicate in terms of welcome the visitor, call others on the phone, or picking the phone, communicating through email, communication with neighbors or friends.

- MAnaging financial: Assess how much a person can manage the financial need, paying bills on time.