This assignment would require you to log into my ATI account and complete the as

This assignment would require you to log into my ATI account and complete the assignment under EHR tutor (steps 1 and 2)
Below are the instructions, and should not take more than 30 minutes – 1 hr to complete.
Attached is also the criteria for sucess, so you know exactly what is expected, as well as a copy of the incident report to be filled out.
Log in to your ATI account
Click “EHR Tutor”
Select the correct patient chart for the assignment.
Complete Part I within “EHR Tutor”
Complete Part II within “EHR Tutor”
Complete Part III using the “Medication Error Report” form provided in D2L.
Complete the Discussion Questions in a WORD document and submit them along with the completed “Incident Report” form to the appropriate D2L DropBox.
You come in for your shift and you are assigned to the care for Mr. Williams who has suffered a gunshot wound. Because of the type of injury, he is receiving IV antibiotics in addition to several other orders.
As you finish getting report from the off-going nurse, Mr. Williams calls asking a nurse to come to the room. You enter Mr. Williams room to find that he has developed hives, itching, and shortness of breath. You complete vital signs and find that his respiratory rate is 40 with an oxygen saturation of 92%.
You know that one of the causes for the development of these symptoms is an allergic reaction. {But, keep in mind you will need to call the doctor, you cannot diagnose this and can only document symptoms in chart} You review his medications in the EHR. His allergies are not listed in the EHR. Suspecting an allergic reaction you approach the patient to confirm the allergies. He tells you that he is allergic to Kefzol which is the same a Cefazolin. You also see in the MAR where his first dose of Kefzol was given 1 hour before the beginning of the shift. See your orders and MAR to confirm what has happened.
You immediately call the physician who orders Benadryl 50 mg IV every 6 hours for itching. The physician also orders that the patient be monitored every 1 hour for 6 hours. The antibiotic is changed to Rocephin 1 gm IV every day. You also notify your immediate supervisor. The patient is notified of the error that has taken place as well as the actions being taken.
Once this is accomplished you must then complete the incident report as outlined by hospital policy.
Begin writing the first nurse’s note (Part I). The content would be as follows: You do not state the words “medication error” in your note, but stick to the facts as they occurred. This error will be documented in the nurses note in narrative form. Under “Nurses Note”, choose
make a new note
professional role-nurse
title it “nursing note”
Include the following information in your first nurse’s note:
Called to patient’s room
Patient found to have hives over entire body and generalized itching with elevated respirations.
Vitals signs Bp 130/80, heart rate 100, Respirations 40, O2 saturation 92%
Physician called and notified of the patient’s complaints.
After reviewing the medications, the physician orders Benadryl 50mg IV every 6 hours
Orders given to discontinue Cefazolin and start Rocephin/ceftriaxone 1 gm IV every day
Patient will be assessed including vital signs every 1 hour as ordered observing for worsening signs of reaction or respiratory distress
Patient given call light and instructed to call if itching unrelieved after Benadryl or if symptoms get worse.
Patient notified of the medication change and the subsequent actions.
You do not include in the note that you completed the incident report. That is an internal document that follows hospital policy and is not a part of the medical record.
Normally, you might complete sequential notes as the situation plays out since it is potentially life threatening. But for our class, you will complete a brief follow up note at hour 6 to show that you completed the orders and that you have assessed the patient for response to treatment.
Begin writing the second nurses note, under “Nurse’s Note” choose
make a new note
professional role-nurse
title it nursing note
Include the following information in your second nurse’s note:
Patient is resting comfortably and no signs of distress
Vital signs are: (He’s better so I would like for you to decide what they are now)
Hives and itching have resolved.
Patient tolerate Benadryl well
Call light within reach
Notified to call for any needs or if symptoms return
Complete the debriefing questions (Part II). This can be limited to a 1 paragraph (3-8 sentences). If you do a few more, that will be fine.
Describe what you see as the importance of the EHR nurses note in this situation.
Also, include the communication role of the EHR in this situation
The scenario mentioned that the chart did not have allergies listed. Give your impression of this fact.
Complete the Medication Error Report (Part III). This is an internal report for quality improvement. purposes.
****COMPLETE THIS DEBRIEFING QUESTIONS IN A WORD DOCUMENT****