Question

The following information was documented in the progress note: Ms. Garcia called with complaints of right-upper quadrant abdominal pain that gets worse with eating. She has been using TUMS for relief and feels better when sitting up. Will make appointment with Dr. Anderson for tomorrow. It was determined that the pain Ms. Garcia was describing was in the left-upper quadrant, not the right as documented. The medical record will need to have an addendum noted. Describe what should be written in the addendum.

Answer 1

This correction is important for accurate assessment and future reference. It has been verified that Ms. Garcia's pain is situated in the left-upper quadrant, and not the right. No other changes to the initial documentation are necessary.

In the addendum to the progress note, it's crucial to accurately correct the information regarding Ms. Garcia's abdominal pain location. Begin by clearly stating that an error was identified in the initial documentation and provide the correct details. For example:

Upon further review, it has been noted that the location of the pain was inaccurately documented as the right-upper quadrant. The correct information is that Ms. Garcia reported pain in the left-upper quadrant, not the right as initially documented."

Answer 2

An addendum to Ms. Garcia's medical record should note the correction of the abdominal pain location from the right-upper to the left-upper quadrant, which is relevant for diagnosing conditions like peptic ulcers.

Step-by-step explanation:

An addendum to medical records should always be clear, factual, and concise. In the case of Ms. Garcia's documentation error, an appropriate addendum may read:

Addendum: Correction of Abdominal Pain Location

Please note a correction to the progress notes dated [original date of documentation]. Upon further clarification with Ms. Garcia, it has been confirmed that the abdominal pain she experienced was located in the left upper quadrant (LUQ), not the right-upper quadrant (RUQ) as previously documented. All subsequent assessments and treatments should take this corrected information into account.

This addendum corrects the record to ensure future healthcare providers are not misled by the original documentation error. Abdominal pain in the LUQ can be associated with conditions such as peptic ulcers, gastritis, or issues related to the spleen or pancreas.