Situation Writing Progress Explained for Students (Easy Guide)

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Original Question

Situation I am writing the progress note of Mr. G.R. He is making excellent progress and will hopefully be discharged on Saturday, 5/17/25 to return home. Mr. G. R. is a 59-year-old male patient, with a PMHx of cerebral palsy, who was admitted to The Miriam Hospital on 5/3/25 with a right hip closed fracture. Five days after a fall, the patient arrived at The Miriam Hospital unable to walk. The patient reported that he lost his balance, walked against a wall, and fell onto his right hip. The patient’s severe ache gradually turns into a throbbing agony that prevents him from walking because his right leg is unable to support his weight. The patient stays at home and lies prone in bed most of the time, but he crawls to use the restroom or kitchen. The patient’s relatives want him to visit the hospital. VS is stable, and the CBC and BMP are unremarkable in the TMH ED. A right non-displaced greater trochanteric fracture was seen on imaging. ED evaluated the patient, made orthopedic contact, and suggested cautious PT/OT. After being admitted to TMH, the patient was sent to Kent’s rehab facility 48 hours later. Immediate concerns are patients’ mobility, ability to do his ADLs, hydration, preventing thromboembolism, controlling pain, and skin integrity as well as pressure injury wound healing. Background Mr. K.H. has no known drug allergies. Full Code. He denies ever being a smoker, states that he drinks a couple of beers a night, and has never used an illicit drug. Patient does not have any significant surgical background in our system, but patient stated undergoing surgery in June 2005 for colorectal cancer – Colostomy LLQ 06/2005. His significant surgical background includes right. Patient does not have any significant surgical background in our system, but he shows signs of a history of cerebral palsy; he stated to have been diagnosed with hypertension twenty-seven years ago and colorectal cancer twenty years ago. Attending Tavares Robert, MD. Medications: Atenolol for hypertension, Enoxaparin to prevent blood clots, Acetaminophen for Mild to moderate pain, Oxycodone for moderate to severe pain, Tamsulosin for urination, Multivitamins with minerals for nutritional supplements, Polyethylene Glycol for constipation, Collagenase Topical for skin and wound ointment, and Senna-Docusate for his constipation. Diagnostic tests include an X-ray of his right leg shows a right non-displaced greater trochanteric fracture. Patient has a closed right hip fracture. He has followed his medication regimen carefully during this stay. His siblings (sisters) remain involved in his care, and he retains his ability to make medical decisions. He has been working with PT and OT a couple of times a day to improve the strength of his lower extremities, balance and increase independence. Assessment During today’s assessment at 1045, the patient’s vital signs showed a normal blood pressure at 128/78 left brachial, using a manual BP device, adult cuffs, sitting position; heart rate 76, respiratory rate 16, temperature 98.6°F, and oxygen saturation 97% on room air. The patient subjectively has no pain or shortness of breath, but he expresses feeling of discomfort around his right hip when doing physical activity. Physical examination reveals clear bilateral lung sounds without cough, crackles, or wheezing. The cardiovascular assessment shows regular heart rate and rhythm without murmurs or gallops and no peripheral edema. The patient is alert and oriented x4 with clear but delayed speech and equal bilateral pupillary response. The musculoskeletal examination demonstrates left-hand grasp strength of 5/5 and right-hand grasp of 3/5. Client requires 1-person moderate assistance with ambulation using a rolling walker. The patient was assessed as a high fall risk with a Morse fall score of 55. The integumentary assessment shows warm, dry skin, frail and fragile skin (Braden Scale: 19). Pressure injuries were observed [Coccyx- stage 3 PI- dressed with Mepilex bandage. Debrided on 5/14. Wound is 1.5cm long and 0.8cm wide. Clean by wound care nurse weekly or when soiled. Right arm – Left arm- dressed with Mepilex for padding- no bruises in those areas- some skin peeling is shown on the right elbow. Right leg- Proximal end shows an Abrasion- Debrided on 5/14. Wound is 1cm in length and 0.4cm in width. Clean by wound care nurse weekly or when soiled]. GI/GU systems usually function with the patient’s bowel and bladder. The last recorded bowel movement was on 5/14. Client independently cleans and changes the colostomy bag each morning. Recommendations?

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