Site Evaluation Presentation Summary Rotation 7 LTC

During my site evaluation, I presented an 85-year-old man presenting for short stay rehab who was recently discharged from the Manhattan VA post treatment for fall and acute episode of pneumonia and CHF exacerbation. I made sure to outline his whole hospital course as well as his status prior to this incident within regard to his ambulation, independence, or dependence in ADLs and IADLs, and living situation. The patient had no acute complaints at the time of my visit with him other than a mild cough that he stated was resolving. I outlined the neurological exam I did on him in detail due to his recent fall. I also made it a point to outline all his medical problems and treatments in the assessment and plan section of the H & P. During my site evaluation I received feedback on the structure of my HPI. I was unaware that I as supposed to include some of the main factors from the geriatric assessment in the HPI, however after being informed by my site evaluator I made it a point to make this correction for my final site evaluation. For my final site evaluation, I presented a 42-year-old male who was discharged from the Manhattan VA in January post frostbite diagnosis, amputation, and debridement of multiple digits. I made sure to include his status within regard to housing and ADLs as well as IADLs to the HPI this time. Again, I also went into detail regarding the assessment and plan making sure to outline all his medical conditions and the treatment, as well as outlining any changes. I received thorough feedback from my evaluator and will use this criticism to elevate my future h and p site evaluations. 

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