Charting Patients
Human Resources Management (HRM)
Paper instructions:
The discussions in this course are designed around helping you look at the practical application of the terms that you are learning in this course. Consider the following questions in light of applying what you have learned thus far in the course.
Would it ever be sufficient to document that a patient has a “rash” in the medical record without further explanation? Why or why not?
A rash is a body disorder affecting the skin where the color and texture of the skin changes gradually. The skin changes resulting in an outbreak of bump-like red patches and these patches differ depending on the cause of the rash (Huber, Kim, Reed, Carrasco, Feldman, Hong & Spencer, 2017). A skin rash may develop as a result of fungal viral or bacterial infection and these causes may be directly or indirectly. A rash maybe as a result of other factors such as chronic illnesses or allergic conditions. When it comes to rash description, it is not sufficient enough for a medical practitioner to indicate the term rash in a medical record without further explanations.
One of the reasons why a health practitioner needs to add more information in a health record concerning skin rash is because skin rash occurs in different forms. A health practitioner needs to note the different characteristics that different forms of skin rash show. These characteristics include primary and secondary morphology, distribution of the patches, patches configuration, and the color (Huber, Kim, Reed, Carrasco, Feldman, Hong & Spencer, 2017). For the primary morphology, a health practitioner will need to explain whether the skin patches are flat or elevated. If the skin patches are elevated, the doctor needs to include in the record the size of elevation. Such detailed information is essential especially in determining the type of medication the patient needs to take.
Another reason why a medical practitioner will need to indicate more information concerning skin rash is that further information can be of significant use in the future. Information especially describing the cause of the skin rash is can help an individual to access the right medication in the future if the skin rash appears again (Huber, Kim, Reed, Carrasco, Feldman, Hong & Spencer, 2017). Also, detailed information can be of great significance especially where the skin rash is a result of chronic illnesses. Another importance of detailed information is that a patient can get the right medication in the future if one decides to obtain medication directly from a chemist without going through the diagnosis process.
References
Huber, A. M., Kim, S., Reed, A. M., Carrasco, R., Feldman, B. M., Hong, S. D., … & Spencer, C. (2017). Childhood arthritis and rheumatology research alliance consensus clinical treatment plans for juvenile dermatomyositis with persistent skin rash. The Journal of rheumatology, 44(1), 110-116.
