Sample Nursing Observation Paper

On 11/16/17 I met Mr. Larson at the office of Dr. Quinn. Mr. Larson is alert and oriented. He is willing to work with a nurse case manager and to provide his medical history. Mr. Larson is alert and oriented.

MEDICAL FACTORS

On 9/1/17 Mr. Larson was at work. He is a mechanic technician. He reports he was holding a weighted object that was 40 to 50 pounds and turning a bolt at the same time. As he was pushing on the object he felt a pop in the small finger. He has been unable to bend the finger since. Mr. Larson reports that he is catching the finger on things because he is unable to bend it. Mr. Larson had a surgical repair of the tendon with Dr. Quinn on 11/7/17.

DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS

Dr. Larson
Quinn reports the tendon was retracted and balled up down by the wrist. He was able to pull it forward and secure it. He said he attached the “stump” to another tendon. He hopes that doing that will give his fingers enough flexion and extension so he can make a fist. Before the surgery, the finger just “hung” out there straight. The sutures were removed from the incision. Today Dr. Quinn wants Mr. Larson to be fitted with a brace to splint with a hand specialist at Comprehensive therapy. He cautions Mr. Larson that he cannot move that hand. Dr. Quinn provided the name and number of the therapist he wants Mr. Larson to see in the Lapeer area close to his
Larson said he injured tendons in his right arm in 1995.

FAMILY/SOCIAL/FINANCIAL FACTORS

Mr. Larson reports his wife is very supportive. If he needs any help she is willing and able to help him. He denied any difficulty in functioning within his home.
Emergency Contact –Mrs. Larson 810-441-8955

PHYSICAL DESCRIPTION

Height: 5 foot 10 inches
Weight: 275 pounds
Hair: grey
Eyes: brown
Dominant hand: right

CLIENT’S FUTURE PLANS

Mr. Larson said he would like to recover and resume his normal life and work activities

CONSENT/EXPLANATION OF CASE MANAGEMENT

I explained my role as a medical case manager and Mr. Larson verbalized understanding. He read and willingly signed the Authorization For Release Of Medical Information form.

ATTORNEY

Mr. Larson denied any legal representation.

IMPRESSIONS

Mr. Larson is a nonsmoker, he reports his overall health is good. The Offical Disability Guidelines for a flexor digitorum profundud tendon of the left 5th digits is 28 to 140 days of recovery. Treatment has been appropriate.

PLAN/ RECOMMENDATIONS

1. Contact Mr. Larson every 2 to 4 weeks. Obtain an update on his current medical status.
2. Attend the appointment with Dr. Quinn on 11/30/17. Obtain a current work slip and projections for