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Emergency Department Record

Identify and list the top 10 most important documents within the electronic health record. Discuss the importance of each document for clinical documentation improvement purposes. Select any 10 from the listed documents below for your discussion:

  1. Discharge Summary
  2. Emergency Department Record
  3. Glasgow Coma Scale
  4. Vital Signs Flowsheet
  5. Problem List
  6. History and Physical
  7. Progress Notes
  8. Consultation Reports
  9. Diagnostic Test Results
  10. Physician Orders
  11. Anesthesiology Record
  12. Operative Reports
  13. Medication Administration Record
  14. Ventilator Flowsheet
  15. Wound Care Notes

Sample Solution

agree with Oberdorfer that Gorbachev is an important factor that led to the end of the Cold War because if he wasn’t in charge, things would have most likely carried out in the same manner as before. For example, the Soviet Economy would have fallen drastically even faster than it fell under his leadership, thus the big impact Gorbachev had through managing the economy in a better way than others, creating or enforcing relationships with leaders such as Reagan and being more active than previous members changed the outcome of the Cold War. After the demise of the previous leader, Chernenko, Reagan sent his vice president, Bush to the funeral to meet Gorbachev, the new leader who was going to induce “serious change” to the Soviet Union, and bring it out of “its long time troubles”. This positive perception did not become reality because of the breakup of the Soviet Union and the loss of power and control over the Eastern European countries, hence why we cannot ignore the vast importance of Eastern European countries gaining independence as the main cause of the end of the Cold War. Gorbachev’s leadership was not inadequate but, Levesque argues, when he needed to focus on the Eastern countries, he did the exact opposite and focused on the West. Moreover, he offered no financial support to those who wanted change in the Eastern European countries since the Soviet Union’s economy was rapidly declining as evident in the Soviets increased the price of oil exports. Therefore, it is quite apparent that the Cold War ended as a result of the lack of control the Soviet Union had over Eastern European countries. Comparison: Levesque has the most valid interpretation because the breadth of it is larger than Oberdorfer’s and Pemberton’s interpretations. Levesque ultimately argues that the Cold War’s end was a result of the Soviet Union’s sheer lack of control of Eastern European countries. His argument is articulate in exploring the reason of the end of the Cold War as well as exploring other contributing factors such as the Soviet economy and how its status was slowly dissolving the Soviet diplomacy and the impact of the Afghanistan War on them, which is further explored by Reuveny and Prakash. Therefore, Levesque’s interpretation is considered objective as he takes a holistic approach in viewing the majority of the factors that contributed to the end of the Cold War, then pinpoints the most impactful one- the lack of control of Eastern European countries and their attainment of independence. Similarly to Levesque’s interpretation, Pemberton and Oberdorfer touch on the Soviet economy and how it led to a diverse variety of distasteful issues for them. Therefore, it could be said that the economic status of the Soviet Union led to the problems they faced- if it wasn’t an issue in the first place, it would not have led to so many other problems that the Soviets had to deal with, but this does not mean that it was the primary reason to the end of the Cold War as it was only a trigger for many issues that arose. Instead of eliminating them, Gorbachev ignored them which led to their aggravation- Eastern European countries gaining independence. However, Oberdorfer argues that Gorbachev’s leadership was the reason as to why the Cold War ended. Several historians have interpreted Gorbachev’s leadership as the main reason to the Cold War’s end, which suggests it is per
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