Chart Review #2:

Select a medical record from the Example Medical Records module (located at bottom of the Modules page) and review all documents within the record. Create a PowerPoint presentation with voiceover on each slide that guides viewers through the patient's chart. Submit your presentation as a PowerPoint file (do not convert to PDF as you will lose your voiceover).

Your PowerPoint must include at minimum:

  • Chart ID (use file name – if this is missing, I will not grade and you will receive a zero for the entire review!!)
  • A brief summary of the patient (demographics)
  • History of present illness
  • Information from progress notes (how did the patient's hospital stay go)
  • Information from orders (what types of medications and other treatments were ordered)
  • Description of treatment given, including therapy and/or (operative) procedures
  • What did the pathology show if a specimen was removed?
  • Was the patient discharged to home or another location? 
  • What was the final diagnosis?

Your voiceover must add substantial information beyond what is on the slides – do not read directly off the slides as you will lose points! If your presentation does not include voiceover, you will receive a zero!

  • Face Sheet
  • ER Record
  • Discharge Summary
  • H&P
  • Progress Notes
  • Orders
  • Operative Report
  • Pathology
  • Medications
  • Graph
  • Nursing Assessment & Notes
  • Discharge Assessment

,

  • Face Sheet
  • ER Record
  • Discharge Summary
  • H&P
  • Progress Notes
  • Orders
  • EKG
  • Medicaton
  • Graph
  • Nursing Assessment & Notes
  • Discharge Instructions

,

  • Face Sheet
  • Discharge Summary
  • H&P
  • Consultation
  • Progress Notes
  • Orders
  • EKG
  • Lab
  • Medication
  • Nursing Assessment & Notes

,

  • Clinical Resume
  • H&P
  • Consultation
  • Progress Notes
  • Orders
  • Cardiac Cath
  • Operative Report 1
  • Operative Report 2
  • EKG
  • Radiology
  • Laboratory
  • Medication
  • Nursing Assessment & Notes
  • Discharge Instructions