72 yo F pt c/o chest pain, rapid HR, and SOB
Hx: CABG 2 wks ago, CHF, DM, HTN
Assessment: VS stable, HR 120 bpm, BP 130/75, O2 sat 99%
Tests ordered: echo, EKG, cardiac cath
Rule out: cardiomyopathy, vessel rupture
Create nursing care plan pending test results
Imagine you are a medical transcriptionist at a physician’s office. In your position you must take the care provider’s notes and either transcribe them or write them out and say them in a clear and concise way. For this activity, you will be transcribing the notes of the cardiac technologist working in the office.
Step 1: Read the Cardiac Technologist’s Notes
72-year-old female patient arrived at office complaining of chest pain, rapid heart rate, and shortness of breath
History: coronary artery bypass graft surgery two weeks ago, congestive heart failure, diabetes mellitus, and high blood pressure
Assessment: vital signs stable but has rapid heart rate of 120 beats per minute, blood pressure is 130/75, oxygen level is 99%
Tests ordered: ultrasound of heart, electrocardiogram, cardiac catheterization
Rule out: heart muscle disease and blood vessel rupture
Create nursing care plan once results are received from tests
Step 2: Transcribe the Notes
Transcribe the notes from the cardiac technologist working in the office. When writing the transcription use the common abbreviations.
3 answers
write it like a human wrote it
A 72-year-old female patient came in today with complaints of chest pain, a fast heart rate, and shortness of breath. Her medical history includes having coronary artery bypass graft surgery two weeks ago, congestive heart failure, diabetes mellitus, and high blood pressure.
During the assessment, her vital signs were stable, but her heart rate was high at 120 beats per minute. Her blood pressure was 130/75 and her oxygen level was 99%. The cardiac technologist ordered an ultrasound of the heart, an electrocardiogram, and a cardiac catheterization to investigate further.
The goal is to rule out heart muscle disease and blood vessel rupture. A nursing care plan will be created once we have the results from the tests.
During the assessment, her vital signs were stable, but her heart rate was high at 120 beats per minute. Her blood pressure was 130/75 and her oxygen level was 99%. The cardiac technologist ordered an ultrasound of the heart, an electrocardiogram, and a cardiac catheterization to investigate further.
The goal is to rule out heart muscle disease and blood vessel rupture. A nursing care plan will be created once we have the results from the tests.