US Healthcare Systems Module 5 Case Scenario

The purpose of this assignment is for you to become familiar with the components of medical charts in order to understand how they are used in providing good health care.

Download and complete this Medical Chart Template for a patient who has alcohol poisoning. The patient demographics and chief complaint have been provided. Please invent the details for any components which do not require specific/accurate facts.

  1. Include all the components of a medical chart.
  2. Use accurate information for the symptoms the patient would be experiencing.
  3. Answer the discussion questions at the end of the chart using correct grammar and accurate information. Write a 1-2 paragraph response for each question.
  4. Use references; remember to use APA format and cite your information.

    Medical Chart

    Name               Nick Morris                              Age      17               Gender     

    Date    _______________   

    Chief complaint

    Patient is carried into the ER by several friends. They say he passed out during a party and they don’t know what’s wrong with him. They are not sure how long he has been unconscious. They were asked if he had been drinking, and they say that he has been drinking all night. One friend says he seemed confused at one point.

    Medical history

    Replace this with your text.

    Habits (tobacco, alcohol)

    Replace this with your text.

    Family history

    Replace this with your text.

    Surgical history

    Replace this with your text.


    Replace this with your text.


    Replace this with your text.

    Physical Exam

    Replace this with your text.

    Discussion Questions

    1. How does a medical chart help diagnosis and treatment?

    2. How might incomplete information on a medical chart cause a misdiagnosis of the problem or condition or delay treatment that could be life-saving? In Nick’s case, his friends could provide information on what he had been doing prior to his visit to the Emergency Room. What if Nick’s friends could not provide complete information? How would this affect his care?

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