John woke up at 7am today and had gluten-free toast for breakfast (he is allergic to gluten). After breakfast he moved his bowels, which is when he noticed central chest pain/heaviness, radiating up to his left jaw. He also noticed some tingling down his left arm and was so nauseated that he vomited his breakfast. John immediately took his morning tablets of aspirin and Perindopril, which he takes for angina and hypertension. John tried resting but this didn’t help the pain. The pain was an 8/10 despite these medicines so he took 1g paracetamol and decided to present to you for further treatment. 1. What is the SAMPLE? Explain each
John woke up at 7am today and had gluten-free toast for breakfast (he is allergic to gluten). After breakfast he moved his bowels, which is when he noticed central chest pain/heaviness, radiating up to his left jaw. He also noticed some tingling down his left arm and was so nauseated that he vomited his breakfast. John immediately took his morning tablets of aspirin and Perindopril, which he takes for angina and hypertension. John tried resting but this didn’t help the pain. The pain was an 8/10 despite these medicines so he took 1g paracetamol and decided to present to you for further treatment. 1. What is the SAMPLE? Explain each
Chapter19: Documentation And Medical Records
Section: Chapter Questions
Problem 2AE
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John woke up at 7am today and had gluten-free toast for breakfast (he is allergic to gluten). After breakfast he moved his bowels, which is when he noticed central chest pain/heaviness, radiating up to his left jaw. He also noticed some tingling down his left arm and was so nauseated that he vomited his breakfast. John immediately took his morning tablets of aspirin and Perindopril, which he takes for angina and hypertension. John tried resting but this didn’t help the pain. The pain was an 8/10 despite these medicines so he took 1g paracetamol and decided to present to you for further treatment.
1. What is the SAMPLE? Explain each
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