Notes on Notes Answer Sheet

Read the following notes. Rewrite the notes to correct grammar, spelling, capitalization, and sentence structure. Remember the notes should be clear, concise, complete and correct, and where appropriate, address the participant’s concern, what was discussed, the participant’s plan, and the follow up plan. Information found elsewhere in the participant’s WOW record should not be included.

Original note / Edited note
Risk Condition: Celiac Disease, Depression, Low Hemoglobin/Hematocrit
Intake: Inadequate vitamin/mineral intake
Clinical: Altered nutrition-related laboratory values
Intervention/Care Plan: Referral to RD with special expertise
Comments: Amber in today for NC, she stated she was in hospital last week to receive an IV iron infusion for anemia. She was told that other vitamin absorption could be effected due to her intolerance for gluten in her diet. Today, her Hgb is 10.4, explained at this time in her pregnancy we like to see it at or above 10.9. She stated she eats meats, it is just her body does not absorb the iron and possibly other B vitamins. She is stall at the “why bother” with changing her diet. She feels mo matter what she eats, that her body does not absorb the nutrients.
She wants to go back on her antidepressants after delivery, so she does not want to breastfeed. She wants back on Celexa and clonipin. She knows breast is best, but she wants to feel better. She is to call after delivery. Gave her a handout on Pre-term delivery because she is having cramping twice per day, and she is worried about it. / Participant’s concern:
What was discussed:
Participant’s plan:
Follow up plan:
Risk Condition: Low Hemoglobin/Hematocrit
Intake: Inadequate vitamin/mineral intake
Intervention/Care Plan: CPA Recommendation
Comments: Discussed the importance of iron for growth; went over some WIC foods that are good sources of iron, like beans and some that are enriched with iron, like cereals; Also discussed vitamin C’s role for better absorption of iron from plant sources.
FOOD PRESCRIPTION NOTE
Audrey is an exclusively breastfed baby. She was born at 39 weeks by C-section. Her birthweightwas 7.9 lbs. Mom states she was 7.1 lbs. when she left the hospital. She has gained 1 oz. daily since hospital discharge. 16 more lines of notes.
Goal: EAT MORE MEATS
(2 years old)
ADMINISTRATIVE NOTES
Notes: Infant is doing ok with Soy formula with cereal but tolerates SImilac Sensitive for spit Up better. Gave mother a note for the dr.
ADMINISTRATIVE NOTES
SMITH, LINCOLN: MOTHER WILL CHECK WITH MILITARY DR ABOUT LINCOLN’S SKIN RASH. SUGGESTED TO MOTHER TO ASK DR IF HE THOUGHT IT COULD BE A MILK ALLERGY AND TO ASK FOR A REFERRAL TO A DERMATOLOGIST IF NEEDED. HIS HANDS WERE VERY BROKEN OUT AND BLISTERED. HE HAS FLARE UPS. REVIEWED FOODS THAT WOULD CAUSE FOOD ALLERIES.
PARTICIPANT FOCUSED NOTES
Note: Left message on voicemail for Angie to return my call so that we could reschedule her missed appt. from today.
PARTICIPANT FOCUSED NOTES
Received a call from food lion in smallville, that they have a w.i.c. check that needs to be signed by participant. Contacted participant but was only able to leave a msg. she was instructed to go to the customer service desk and sign the WIC check to complete the WIC purchase. Left my name and number to call if she has any questions. / Participant’s Concern:
What was discussed:
Participant’s plan:
Follow up plan: