Clinical Log Detailed Report | Chamberlain College Of Nursing 2023

Clinical Log Detailed Report – Chamberlain College Of Nursing. Course Name: NR511: Differential Diagnosis and Primary Care Practicum (10871) Course Section: Section- 0 Course Session: May 2019 Faculty: Washington, Cynthia Preceptor: Williamson, Danny Clinical Site: Affordable Quality Care Log Date: 05/10/2019 Last Updated: 05/29/2019 Minutes: 00:25 Date Of Clinical: 05/08/2019 Patient Initials: JP Age Range: 12-17 years Gender: Female Ethnicity: Hispanic or Latino Client Complexity: Episodic (Acute Condition) Student Level of Function: 25% Student/75% Preceptor Type of Site: Family Medicine Type of Visit: Acute / Episodic Care Physical Exam: Cardiac, Constitutional / Vital Signs, Heent, Medical Reconciliation, Respiratory Type of Diagnostics: Laboratory Ordering Diagnostics: Rapid Flu testing, Strep Screen (Rapid) Procedures: Medications: Respiratory Agents Therapeutics: Initiate medication Education Comments: Medication Administration Referrals: N/A Follow-up: 1 month Coding: -Acute nasopharyngitis [common cold] -Acute pharyngitis -Other seasonal allergic rhinitis -Fever presenting with conditions classified elsewhere Skills & Procedures: N/A Notes: 99214 Establish level 4 visit Diagnostic: Strep test and influenza test both negative Prescribe zyrtec and flonase Education: Take zyrtec to help w/allergic rhinits and flonase to help w/nasopharyngitis.  drink plenty of fluids to stay hydrated.  s/s to look for dehydration.  Take tylenol for fever and use as directed on the label. Scott, Dorothy Page: 8 Course Name: NR511: Differential Diagnosis and Primary Care Practicum (10871) Clinical Site: Affordable Quality Care Log Date: 05/10/2019 Patient Initials: AE Age Range: 1-4 years Course Section: Section- 0 Last Updated: 05/29/2019 Gender: Male Course Session: May 2019 Minutes: 00:30 Ethnicity: Hispanic or Latino Faculty: Washington, Cynthia Date Of Clinical: 05/08/2019 Client Complexity: Episodic (Acute Condition) Preceptor: Williamson, Danny Student Level of Function: 25% Student/75% Preceptor Type of Diagnostics: N/A Education Comments: Asthma action plan Type of Site: Family Medicine Ordering Diagnostics: N/A Referrals: N/A Type of Visit: Acute / Episodic Care Procedures: Follow-up: 1 week Physical Exam: Cardiac, Constitutional / Vital Signs, Heent, Medical Reconciliation, Respiratory Medications: Anti-Asthmatic Agents Therapeutics: Disease Specific Teaching Coding: -Cough variant asthma Skills & Procedures: N/A Notes: 99214 Established level 4 visit Prescribe Flovent HFA inhaler and spacer Education: signs to look for triggers, SHOB and when to utilize rescue inhaler.  drink plenty of water to stay hydrated and prevent thickening of fluids. Scott, Dorothy Page: 9 Course Name: NR511: Differential Diagnosis and Primary Care Practicum (10871) Clinical Site: Affordable Quality Care Log Date: 05/14/2019 Patient Initials: EV Age Range: <1 year Course Section: Section- 0 Last Updated: 05/29/2019 Gender: Male Course Session: May 2019 Minutes: 00:25 Ethnicity: Hispanic or Latino Faculty: Washington, Cynthia Date Of Clinical: 05/14/2019 Client Complexity: Episodic (Acute Condition) Preceptor: Williamson, Danny Student Level of Function: 25% Student/75% Preceptor Type of Diagnostics: Laboratory Education Comments: Disease Understanding Type of Site: Family Medicine Ordering Diagnostics: Blood Test Referrals: N/A Type of Visit: Acute / Episodic Care Procedures: Follow-up: 1 week Physical Exam: Cardiac, Constitutional / Vital Signs, Gastrointestinal, Heent, Medical Reconciliation, Respiratory Medications: N/A Therapeutics: Disease understanding Coding: -Unspecified jaundice Skills & Procedures: N/A Notes: 99213 establish level 3 visit diagnostic repeat bilirupin ordered for tomorow Educated: patient to place baby in sun light and have test repeated and to ensure that pt is eating appropriately in order to increase bowel movements. Pt presnet w/parents who state they want to review the patients lab results.  Mother states that the baby nurses every 2-3 hours for about 15 min on each breast and stools on average of every other feeding.  reports that his stools continue to be yellow and seedy.  Lab results showed an elevated billirubin.  will have billirupin repeated.