Fictional chart assignment (FCA) 2

Your hypothetical patient is described below. Some basic data are provided; the rest of the clinical details are up to you to invent. You should document this patient's medical care in your office over the span of 6 months, beginning with the visit described below. (You do not need to retrospectively create notes for visits that have gone before. However, we assume that these notes exist, and you may refer to them in the notes that you do write.) By the end of the six months, the patient's problems should be well-controlled, or resolved. Create notes for as many office visits as you think are necessary, at intervals that you think are appropriate for the scenario you create. There is no required number of notes or frequency of visits. You can make it as simple or as exotic as you want. Exotic does not mean long. Nor does simple mean short. Length doesn't matter, and making your note longer won't make it better. What matters is maximum information density.

Write chart notes, specific to this patient. Do not write a term-paperish general essay on the problems or diagnoses. If you wouldn't write it in a patient's chart, then don't write it in this assignment.

Submit your work via Blackboard.

Don't spend time making it look all nice and pretty; I'm interested in the content of your thoughts, not the appearance of your writing on the page.

Here is your case:

A 45 year-old woman, a long-time patient of yours, presents with a back injury. She works as a nurse's aid, and yesterday while lifting a patient, she developed sudden onset low back pain. She's never had back trouble before. Today her BP is 168/98, similar to several previous readings at earlier visits for unrelated problems.