For CELBANPrep Writing IENs are encouraged to write both incident reports and assessment reports. Each assignment is reviewed several times, by a writing coach for the Writing Tutoring. Every once in a while I read a report that stands out. I am posting this one online, with permission from the writer.
Please pay attention to the following:
- medical documentation standards,
- avoidance of the word “I”,
- clear descriptions of observations,
- vital signs, and
- advanced punctuation.
This IEN worked hard to turn her weaknesses into strengths, during CELBANPrep Writing Level Two, and has become a master.
Also note, this report was written and edited with in 20 minutes using the skills taught in CELBANPrep Writing Level One and lots of practice.
Use at least six key words from the following: diabetes, insulin, blood sugar level, needle, sugar, exercise
January 6, 2012 @ 01300H. Jessica Yap, 14 years old, came to ER complaining of dizziness. According to her mother, she was recently diagnosed with juvenile diabetes. She does soccer and practices everyday after school for 1 hour.They were celebrating her 14th birthday today. After she ate a piece of her cake, she began trembling, became pale and complained that she was very dizzy, which prompted her mother to bring her to the hospital. Assessment were as follows: lethargic, cold and clammy skin, cyanotic nailbeds. Blood sugar level checked and revealed 400mg/dL. Vital signs were BP 110/80 mmHg, HR 110bpm, RR 23cpm, T 36 C. Dr. Andrew informed. His orders were carried out: PNSS 1000ml x 80ugtts/min started on (L) hand; HR 4 units SQ given; health teachings were given, focusing primarily on strict adherence to insulin regimen and diet, which the mother and the patient reported that they understood. Blood sugar level checked and recorded q hourly. At 0230H, blood sugar level was 200mg/dl. Endorsed to MS ward for continuity of care.——– IA R.N