How information is documented in professional charting


Assignment task: How could the following information is documented in professional charting language:

1) Client's abdomen looks swollen and rounded, tender when touched just below the belly button.

2) Dr. Black came in to do a rectal examination on the client at 1000, and he left orders.

3) Client will take only small sips of fluids, even with your encouragement. He says he feels like he's going to throw up.

4) You get your client up in the chair for the first time - 15 minutes. He says he feels great.

5) Client has a terrible cough occasionally. He smokes a lot but never coughs anything up.

6) Your client was sick to her stomach and brought up 1/2 K-basin of breakfast. She felt better afterward. You gave her a partial bath and mouth care. She then fell asleep. She is very pale. 47

7) Client says he has a great deal of very bad pain in his right ankle, which is worse when he moves it. He says it feels like it is on fire. The ankle is red and puffy?

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Other Subject: How information is documented in professional charting
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