DOCUMENTATION CASE STUDY MS. CLARA WOLFE • Mrs. Clara Wolfe – 75 years old • Dr. Sam Smith – primary care physician • Family contact/guardian – Anna Dubois, daughter and her 3 adolescent children share their home with Clara • Medical diagnosis – hypertension, osteoporosis, osteoarthritis, mild cognitive impairment, Type 2 diabetes • Functional – ambulates with a walker The health care aide, Lana Biggs, is scheduled to provide daily personal care assistance for Clara. The HCA calls you, the client home care coordinator at 0800 and reports Clara fell with “minor injuries and a scrape on her left shin”. The. HCA reports to you that Clara fell during the night at approximately 0400 but seems to be fine this morning. The HCA states that Clara fell as she was getting up to use the commode and Clara denies loss of consciousness, Her daughter states that the fall was not witnessed, but she was awakened at night to assist her mother. Clara was placed back in bed by her daughter who says that her mom has been unsteady and slightly confused for the past two days, Clara has a 3 cm abrasion on her leg. You instruct the HCA to monitor pain and mobility issues. You tell the HCA that you will be making a home visit this morning for an assessment of the client’s condition and situation. You visit the home that morning at 1100. You observe a 3 cm abrasion on the left shin. Clara is moving all limbs and has no complaints of pain at this time. BP 130/86, T 37.1 C, P 94, R 22 PEARL. You measure Clara’s blood glucose level. You apply a clean dressing to the wound. Clara tells you that she tried to get up at night and use the bedside commode when she got dizzy and fell. Clara’s physician was notified of her fall and your assessment data at 1230. New orders received for analgesic for pain and urine specimen. Dr. S. Smith is to be notified of results and client’s pain. Make the following documentation: SBAR, Narrative Charting, POMR, SOAP, PIE, DAR