A Student Nurse Looks At A Patient's Chart
Introduction
As a student nurse, one of the most important aspects of my job is to review and analyze a patient's chart. This is a crucial step in providing the best possible care for my patients. It allows me to gain an understanding of their medical history, current conditions, medications, and any other relevant information that will inform my treatment plan.
Medical History
The first thing I look at when reviewing a patient's chart is their medical history. This includes any previous illnesses, surgeries, or hospitalizations. It's important to understand a patient's medical history because it can provide insights into their current condition and potential risk factors for complications.
Current Condition
Next, I review the patient's current condition. This includes any symptoms they're experiencing, vital signs, and lab results. It's important to have a clear understanding of a patient's current condition so that I can provide appropriate interventions and monitor their progress.
Medications
Another important aspect of a patient's chart is their medication list. This includes all prescription and over-the-counter medications, as well as any herbal supplements or vitamins. It's important to review this list to ensure that there are no potential interactions or adverse effects.
Allergies
A patient's allergies are also an important consideration when reviewing their chart. This includes any medication allergies, as well as allergies to foods or environmental factors. It's important to be aware of a patient's allergies to prevent any potential adverse reactions.
Family History
Family history is another important aspect of a patient's chart. This includes any genetic predispositions to certain conditions or illnesses. Understanding a patient's family history can help inform our treatment plan and potential preventative measures.
Previous Tests and Procedures
Previous tests and procedures can also provide important information when reviewing a patient's chart. This includes any imaging studies, such as X-rays or CT scans, as well as previous surgeries or procedures. Understanding a patient's previous tests and procedures can help inform our treatment plan moving forward.
Social History
A patient's social history is also an important consideration when reviewing their chart. This includes information about their occupation, living situation, and any lifestyle factors that may impact their health. Understanding a patient's social history can help inform our treatment plan and potential preventative measures.
Current Care Plan
The patient's current care plan is another important aspect of their chart. This includes any current interventions, medications, or therapies they're receiving. It's important to review the current care plan to ensure that it's appropriate for the patient's condition and that it's being implemented correctly.
Conclusion
Reviewing a patient's chart is an essential part of my job as a student nurse. It allows me to gain a comprehensive understanding of a patient's medical history, current condition, medications, and any other relevant information that will inform my treatment plan. By carefully reviewing a patient's chart, I'm able to provide the best possible care for my patients.