Transcript:Student Documentation Model Documentation

Transcript:Student Documentation Model Documentation

Subjective Data Collection

Objective Data Collection

Education & Empathy


Document: Vitals Document: Provider Notes


Student Documentation Model Documentation


Differential diagnosis: 1. flu-like syndrome or cold 2. strep throat 3. Allergies 4. Allergic rhinitis

My differentials include cold, strep throat, rhinitis, allergies and asthma based on abnormal findings affecting the ears, upper respiratory tract and lymphatic region.


Discuss hand hygiene and hygiene ettiquitte when coughing: cough in elbows, and hand hygiene. Strep culture Cough medication to help sleep at night and suppress cough Antihistamine to dry up secretions Encourage fluid intake, avoid dairy products that can make cough worse: phlem may get thicker Refer for allergy testing if antihistamine did not work Educate warning signs for immediate attention like difficult breathing, fever, chills, or cough worsening. Follow up in a week or telephone appt in 3 days to follwo up on progress Educate the family the importance of hand hygiene

Danny should be referred for an allergy test to rule out allergies a well as a lung function test to rule out asthma. He should receive strep culture to rule out strep throat. I recommend antitussive treatment at night to help with his sleep in addition to bed rest.


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