Question

You have been called to the house of a patient with altered mental status. You encounter a​ 41-year-old male who exhibits slurred​ speech, an unsteady​ gait, and an odor resembling that of alcohol on his breath. His wife states that he is an alcoholic and needs help to get better. When documenting this​ information, which statement would be​ best?

A.Family member states patient ETOH
B.Patient with history of alcoholism
C.Alcoholic history disclosed to EMS
D.Per wifedashpatient has alcoholic history

Answer 1

The most suitable documentation statement for the patient's condition is "Per wife — patient has alcoholic history," as it places the source of information accurately and avoids labeling.

Step-by-step explanation:

When documenting the encounter with a 41-year-old male patient with altered mental status, slurred speech, unsteady gait, and an odor of alcohol on his breath, the most appropriate statement to include in the medical records would be: The best statement to document this information would be: Per wife - patient has alcoholic history. This statement accurately reflects the wife's disclosure of the patient's alcoholism and is concise and professional. It provides important information about the patient's history that can be relevant to their current condition. It appropriately sources the information to the wife, indicating that the history details are from a family member's report.