Organizing Client Information for Mrs. Jan Peters: A Structured Client Record

QUESTION

Activity 7 Design and develop a client record, using appropriate headings and format, to organise the random client information, provided for Mrs Jan Peters, so that it is easily accessible. Vit D deficient (Dr P Hurt) 12/09/20XX Joined organisation 17/10/2011 Born: 12/03/1941 Weight reducing diet (Snr Dietitian) 09/01/20XX Eats eggs, milk and cream Religion: Anglican Dentures Rheumatoid arthritis in right hand Has two daughters interstate, no immediate family locally Vit D supplement (Snr Dietitian) 13/09/20XX Mrs Jan Peters Vegetarian ID 789/0021/73 JAN PETERS Family history of diabetes Suffers from dementia, otherwise healthy physically (Dr P Hurt) Due for knee surgery in six months, weight loss will assist Enjoys desserts Occasional fish Nationality: British Refuses nuts (whole) Drinks insufficient water Daughter Ms Alice Peters, 27 Coulbret Drive Canberra 0415 234 156 Daughter Mrs Joan Selby 411 Geranium Drive Sydney North Husband John Selby 0415 769 223 Medications: Sombatome with meals (antinausea) Client reports Sombatome causing dry mouth and unpleasant taste 20/11/20XX Vit D standard supplement commenced 14/09/20XX Loading dose to 28/09/20XX Review 28/12/20XX Request Dr P Hurt to review Sombatome medication, advise dry mouth/ taste 21/11/20XX

ANSWER

Organizing Client Information for Mrs. Jan Peters: A Structured Client Record

Introduction

Maintaining accurate and easily accessible client records is crucial in healthcare, ensuring that healthcare professionals have the necessary information to provide optimal care. This essay discusses the development of a well-organized client record for Mrs. Jan Peters, highlighting the importance of headings and a structured format to facilitate quick access to her information.

Client Record for Mrs. Jan Peters

Client Identification

Full Name: Mrs. Jan Peters
Client ID: 789/0021/73
Date of Birth: 12/03/1941
Nationality: British
Religion: Anglican

Medical History

Suffers from dementia, but is otherwise healthy physically (as per Dr. P Hurt).
Diagnosis of Rheumatoid arthritis in right hand.
Vitamin D deficiency diagnosed by Dr. P Hurt on 12/09/20XX.
Scheduled for knee surgery in six months; weight reduction is recommended to assist with the procedure.
Family history of diabetes.

Dietary Information

Currently on a weight-reducing diet as per Senior Dietitian’s recommendation (09/01/20XX).
Eats eggs, milk, and cream.
Enjoys desserts and occasional fish.
Refuses whole nuts.
Drinks insufficient water.

Medications

Sombatome taken with meals as an antinausea medication. Client reports it is causing dry mouth and an unpleasant taste (20/11/20XX).
Vitamin D standard supplement commenced on 14/09/20XX, with a loading dose until 28/09/20XX. Further review scheduled for 28/12/20XX.
Request for Dr. P Hurt to review the Sombatome medication due to dry mouth and taste issues (21/11/20XX).

Dental Information

Mrs. Jan Peters has dentures.

Family Information

Husband: John Selby (Contact: 0415 769 223)
Daughters:
1. Ms. Alice Peters, residing at 27 Coulbret Drive, Canberra (Contact: 0415 234 156).
2. Mrs. Joan Selby, residing at 411 Geranium Drive, Sydney North.

Joining Information
Mrs. Jan Peters joined the organization on 17/10/2011.

By structuring the client record with clear headings and a logical format, healthcare professionals can easily access and interpret essential information about Mrs. Jan Peters. This organized record promotes efficient and effective healthcare delivery, ensuring that her complex medical and personal history is readily available for reference and decision-making, thus enhancing the quality of care she receives.