NR 226 iHuman Case Study; EHR Analysis for Vincente Quintona's Assessment
= Vincente Quintona: " ~ , Attending
@® Correct X Missed ¢ Incorrect
Choice Yours Graded
Hypoactive bowel sounds ®
Leukopenia O
Pain 4/10 ®
Hypotensive O
Hypertensive [}
Hyperglycemic &
Hypokalemic |
Diarrhea O
Tachycardia &)
NPO @
Mechanical soft diet O
Penicillin allergy O
Hyponatremic O
24 hours without BM €]
History of colorectal cancer &
Hyperkalemic |
Pain 8/10 O
Nausea @
Hypernatremic O
Colostomy L]
-
l Hyperkalemic
Pain 8/10
Nausea
ROO000O0ONOO0ORNONOO
Hypernatremic
Colostomy
Bradypnea
Bradycardic
Leukocytosis
Hypoglycemic
Pain 6/10
lleostomy
Febrile
Tachypnea
, D e ) e |
@ Correct X Missed ( Incorrect
Choice Yours Graded
Marijuana use [ J
N
Stabbing pain
00O0NOO0ORNOORORNO
Smoker [ J
Needs influenza vaccine
Nausea
Pain 5/10
Family history of hypertension
Bloating
Nonsmoker
Peanut allergy
Pain 8/10
Penicillin allergy
Vomiting
Family history of colon cancer.
Denies drug use
Alcohol use
OO0
Denies alcohol use
Cramping
Pain 2/10
Result Question
I 'am here to perform an assessment.
<
Let me wash my hands before we get started.
NSRS
Are you wearing any fingemnail polish?
Can | take a look at your wristband to confirm your identity?
Do you have any allergies?
N
Have you had anything hot or cold to drink recently?
N
Hello. | am your nurse and will be taking care of you.
N
How are you feeling?
S
How can | help you today?
N
Let me close the curtain/door before we get started.
N
Let me clean my equipment with disinfectant wipes.
N
I am here to take your vital signs.
N
I will keep you informed of the steps in my care and how long it will take.
What happened?
N
What is your name?
R
What time is it?
N
= Vincente Quintona: " ~ , Attending
@® Correct X Missed ¢ Incorrect
Choice Yours Graded
Hypoactive bowel sounds ®
Leukopenia O
Pain 4/10 ®
Hypotensive O
Hypertensive [}
Hyperglycemic &
Hypokalemic |
Diarrhea O
Tachycardia &)
NPO @
Mechanical soft diet O
Penicillin allergy O
Hyponatremic O
24 hours without BM €]
History of colorectal cancer &
Hyperkalemic |
Pain 8/10 O
Nausea @
Hypernatremic O
Colostomy L]
-
l Hyperkalemic
Pain 8/10
Nausea
ROO000O0ONOO0ORNONOO
Hypernatremic
Colostomy
Bradypnea
Bradycardic
Leukocytosis
Hypoglycemic
Pain 6/10
lleostomy
Febrile
Tachypnea
, D e ) e |
@ Correct X Missed ( Incorrect
Choice Yours Graded
Marijuana use [ J
N
Stabbing pain
00O0NOO0ORNOORORNO
Smoker [ J
Needs influenza vaccine
Nausea
Pain 5/10
Family history of hypertension
Bloating
Nonsmoker
Peanut allergy
Pain 8/10
Penicillin allergy
Vomiting
Family history of colon cancer.
Denies drug use
Alcohol use
OO0
Denies alcohol use
Cramping
Pain 2/10
Result Question
I 'am here to perform an assessment.
<
Let me wash my hands before we get started.
NSRS
Are you wearing any fingemnail polish?
Can | take a look at your wristband to confirm your identity?
Do you have any allergies?
N
Have you had anything hot or cold to drink recently?
N
Hello. | am your nurse and will be taking care of you.
N
How are you feeling?
S
How can | help you today?
N
Let me close the curtain/door before we get started.
N
Let me clean my equipment with disinfectant wipes.
N
I am here to take your vital signs.
N
I will keep you informed of the steps in my care and how long it will take.
What happened?
N
What is your name?
R
What time is it?
N
