Medical Chart

Name Nick Morris Age 17 Gender M

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 drinkin g, 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? If the patient’s medical information was not documented in the medical record; then, it didn’t happen. The goal of the medical chart is too medically and legally record the individual’s clinical status, medical and social history, chief complaint, care, and health history. Accurate and specific information is recorded in the medical chart, and it’s intended to provide a complete clinical recording of the person’s condition by detailing diagnoses, treatments, tests, and responses to treatment, and other health issues that affect the person’s health or clinical state. Medical records document facts of patient care, including what was done by whom, and what results occurred. Proper medical documentation help promotes patients’ and physicians’ best interests for different reasons. Making sure that recording all of the patient’s information helps physicians closely monitor what test or other medical exams were performed and completed, and can make the right diagnosis to reduce errors and make the proper medical diagnosis in the treatment process. Proper medical records improve patients’ clinical outcomes once they leave the hospital. Documenting the patient’s health history is a critical component to the delivery of healthcare. It ensures the continuity of care because it serves as a communication tool among healthcare physicians; they plan and evaluate patient’s treatment. It helps to create a permanent record for the patient’s future care and provides effective treatment for the patient.

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? The information which his friends provided to the doctor is precisely right and consistent with what the medical chart contained, including Nick’s medical history, family history, and his habits. The information provided was accurate and much easier for the health provider to understand and prescribe the right medications. Let’s say that Nick’s friends were unable to provide the necessary medical information; there’s a chance of misunderstanding or misinterpreting the wrong medication which can have adverse effects not associated with the current diagnosis or treatment, which can lead to alcohol poisoning which can lead to death.


Medical charts. (n.d.). Retrieved September 9, 2018, from PracticeFusion website:

Assessing Alcohol-Intoxicated Patients. (2018, June 22). Retrieved September 9, 2018, from verywellhealth website:

2018, from verywellhealth website:

Sample write up. (2007, October 1). Retrieved September 9, 2018, from UNC School of Medicine website: sample-notes/sample-write-up-1

Practice Facilitation Handbook/Sample Medical Record: Monica Latte. (2013, May). Retrieved September 9, 2018, from AHRQ website:

Leiner, F., W. Gaus, R. Haux, and P. Knaup-Gregori. Medical Data Management: A Practical Guide. New York: Springer-Verlag, 2003.

Carter, Jerome H. Electronic Medical Records: A Guide for Clinicians and Administrators. Philadelphia: American College of Physicians, 2001.

Get a 10 % discount on an order above $ 50
Use the following coupon code :