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AliceHale_MedicalRecord.pdf
Form 9784 (3/98) mr OPERATIVE RECORD
Surgeon
Assistant
Operation
Anesthesia
Preoperative Diagnosis
Postoperative Diagnosis
Signature Dr.
Sundance HealthCare Systems Painted Valley, USA
HALE, Alice Dr. Audie M. Everett Room 308
3/24/xx # 661944
Dr. A. M. Everett
: Right mastectomy with bilateral breast reconstruction.
General with endotracheal intubation
Fibrocystic disease right breast.
Multi-focal lobular carcinoma in situ with focal stromal invasion, right breast.
Complications: None.
Procedure: The patient is a 50 year-old female who was status post left modified radical mastectomy for breast cancer.
After adequate level of general anesthesia was obtained, the patient’s chest and axilla was prepped in the usual sterile manner. A 20 cm. incision was made from the nipple and extended laterally to facilitate eventual breast reconstruction. Using a combination of blunt and sharp dissection, superior and inferior skin flaps were created. The limits of dissection were the sternum medially, the deltopectoral groove superiorly, the lateral border of the pectoralis major muscle laterally, and the rectus fascia inferiorly. The specimen, which included the entire right breast and a small amount of surrounding subcutaneous tissue was removed from the operative field. Hemostasis was meticulously obtained using electrocautery and 000 chromic ties.
The case was then turned over to Dr. Arie Brushfield of the Plastic Surgery Division, who was to perform the bilateral breast reconstruction.
The estimated blood loss for the initial part of the procedure was approximately 300 cc.
AEV/mk D: 3/24/xx T: 3/25/xx
Audie M. Everett
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
NAME X-RAY NO.
DOCTOR DATE
REGION EXAMINED
M.D. RADIOLOGIST'S SIGNATURE
Alice Hale 4273-aa
Everett 3/24/xx Chest X-ray
HALE, Alice Dr. Audie M. Everett Room 308 # 661944
Chest X-ray: These films were compared to previous films of 11/22/xx. The pulmonary parenchyma, pulmonary vasculature, heart and mediastinal structures are normal.
No interval change is noted. The absence of the left breast shadow is noted.
Impression: Normal chest film, status post left mastectomy.
WCR/bca
William C. Roentgen
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Painted Valley, USA Patient Name:
Physician:
Room No.
Consent for Treatment: I, __________________, voluntarily give my authorization and consent to the performance of the procedure(s) described below, including the administration of blood, by ___________________________________, and his/her associates/assistants, in addition to hospital personnel and other trained persons, as well as the presence of observers.
Complications: I am aware that in the practice of medicine, other unexpected risks or complications not discussed may occur. I also understand that during the course of the proposed procedure(s) unforeseen conditions may be revealed requiring the extension of the identified procedure, performance of additional procedures, and I authorize such procedures to be performed. I further acknowledge that no guarantees or promises have been made to me concerning the results of any procedures or treatment.
PROPOSED PROCEDURES: I understand that the procedures proposed for evaluation and treatment of my condition(s) is (are):
Right � Left � Bilateral �
Tissue Disposal: I hereby authorize Sundance Medical Center to dispose of any tissue(s) or material(s) in their usual manner, with the exception of:
Risks and Benefits: a. Just as there may be benefits to the procedure(s) proposed, I also understand that medical and
surgical procedures involve risks. These risks, including allergic reactions, bleeding, blood clots, infections, adverse side effects of drugs, and even loss of bodily function or life, as well as risks of transfusion reactions and the transmission of infectious disease, including Hepatitis and Acquired Immune Deficiency Syndrome, from the administration blood and/or blood components.
b. I also realize that there are particular risks associated with the procedure(s) proposed for me (him/ her) and that those risks include, but are not limited to, those enumerated in the attachment.
Acknowledgements: The available alternatives, some of which include _____, the potential risks and benefits of the proposed procedure(s), and the likely result without such treatment [ ____ ] have been explained to me. I understand what was discussed with me, as well as the contents of this consent form and have been given the opportunity to ask questions and have received satisfactory answers.
I also understand that the Sundance Medical Center is a teaching and research hospital and that any tissue (including) blood that is recovered during surgery and not required for diagnosis may be used for research and/or teaching purposes.
Patient's Signature Date Time Surgeon
a.m. p.m.
SURGICAL CONSENT
HALE, Alice Dr. Audie M. Everett Room 308
Dr. Audie M. Everett
Alice S. Hale 3/24/xx 7:30 Audie M. Everett
Alice S. Hale
None
Prophylactic right simple mastectomy, followed by submuscular
implant reconstruction of the right breast. Left breast reconstruction with submuscular implant.
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Signature Dr.
Form 9003 (3/93) pa SURGICAL PATHOLOGY
Sundance HealthCare Systems - Painted Valley, USA Patient Family Name First Name Age Room No. Hosp. No.
Attending Physician Date Lab. No.
HALE, Alice 50 308 661944
Dr. Audie M. Everett 3/24/xx # 100325a
Pathologic Diagnosis: Multi-focal lobular carcinoma in situ with focal stroma invasion, right breast. Intradermal scar, left anterior chest wall skin.
Specimen A is labeled scar left breast. It consists of skin measuring 3.4 cm in length and .5 cm in width. There is minimally attached adipose tissue.
Specimen B is labeled right breast. It consists of adipose tissue measuring 12 X 10.4 X 3 cm. Serial section of the adipose tissue shows a central area of fibroids which appears firm and whitish. Multiple blue colored cysts are also noted with the largest measuring .3 cm in diameter. No definite mass could be palpated or seen in the breast tissue.
Micro Pathologic Report:
Specimen A: Scar from the left anterior chest wall. Well-formed intradermal scar without evidence of malignancy.
Specimen B: Representative portions of right simple mastectomy.
Section X1 show severe fibrocystic disease characterized by focal interstitial fibrosis with marked sclerosing adenosis, cystic dilatation of breast ducts and foci of intraductal papilloma formation. Numerous foci of microcalcification are seen.
Section X2 show foci of lobular carcinoma in situ characterized by lobules and terminal ducts filled with population of small cells, having hyperchromatic nuclei and occasional vacuolated cytoplasm. The malignant cells are primarially located within breast arrangement of tumor cells.
CP/et D: 3/24/xx T: 3/25/xx
Robert T. Penneypacker
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
Recovery Room Record
Date
Anesthesia
Operation
Surgeon
Assistant
Anesthetist
Total Anesthesia Time
Arrival
Transfer
Regained
Consciousness/Sensation
Allergies
Preop. BP
POSTANESTHESIA RECOVERY ROOM RECORD
PAR Scoring Index Adm. Dism.
Parameters 0 1 2 0 1 2
Activity
Respirations
Vital Sign Stability
Color
Consciousness
Total Score
PAR Parenteral Fluid Record Intake-Output Summar Total Vol. Time Time IV Site Intake OR .
Type of Fluid Blood Donor # (cc) Begun Ended & Rate PAR
Total
Output: OR
PAR
Total
Assessment at Admission Skin Condition
Responsiveness
Dressings/Drainage
Packs/Drains
Cast/Cirs
Airway
Respirations
O 2
Time DC & Effects
N/G
Foley
Patient Name Attn Phys Room MR #
HALE, Alice Dr. Audie M. Everett Room 308 # 661944
3/24/xx
General
Rt Mod mastectomy, immediate recon
A. M. Everett, A. Brushfield
John Dundee
3' 35"
12:10 p.m.
1:30 p.m.
reactive
12:20 p.m.
PCN
98/60
18 16
G G
Pale Pink
Unc Awake
Dr 1/2 N.S. 1000 + 150 1225 p 1:30 p
2900 3500 6400 5100 510
5610
Clear
18 and shallow
nasal O2 per vent, ell Jackson-Pratt R 50 cc Jackson-Pratt L 50 cc
H & H drawn
Anesthesia used was O2, N2O, morphine sulfate, anectine and sodium pentathol.
Pink, warm and dry on discharge
Brenda Kellye, RN
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Date/ Time
Physician Orders and Progress Notes
Orders
Sundance Medical Center Painted Valley, USA
Form # _ _ _ _
Progress Notes
HALE, Alice Dr. Audie M. Everett Room 308
3-24-xx Anesthesia Note: 50-year-old white
female patient with history of breast carcinoma.
Post status left mastectomy with no apparent
problem with anesthesia.
John W. Dundee
H & P unremarkable. No meds. No allergies
except to Penicillin. Physical exam within
normal limits. Labs OK. Chest x-ray and
EKG Normal. Procedure discussed for the
scheduled right mastectomy and bilateral breast
reconstruction.
Audie M. Everett
3-24-xx Op Progress Note:
Procedure: Prophylactic right simple
mastectomy and bilateral breast
reconstructions.
Surgeon: Audie M. Everett
Estimated blood loss: 600 cc
Drains: 3 JP’s
Complications: 0
The patient tolerated the procedure well.
Standing orders: 3/24/xx
1. EKG
2. PA and lateral chest x-ray
3. Complete Blood Count
4. Urinalysis
5. VDRL
6. Blood Urea Nitrogen
7. Creatinine
8. Blood Glucose
9. Electrolytes
10. Prothrombin Time, Partial Thromboplastin Time
11. Platelets
12. Calcium
13. Phosphorus
14. Alkaline Phosphatase
15. Bilirubin\
16. LDH, SGOT, SGPT, CPK
17. Type and crossmatch 2 units of blood
Audie M. Everett
3-24-xx Admit to surgical unit
HX: breast carcinoma
OR permits
Right modified mastectomy with bilateral
reconstructions
General anesthesia
Allergic: Penicillin
NPO
Phisohex shower
Vistaril 50 mg IM
Demerol 50 mg IM
Audie M. Everett
Audie M. Everett
3-25-xx General surgery: POD 1
Patient without complaints.
Afebrile, Vital signs stable
Imp: doing well.
Plan: Dressing changes prn.
Audie M. Everett
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Date/ Time
Physician Orders and Progress Notes
Orders
Sundance Medical Center Painted Valley, USA
Form # _ _ _ _
Progress Notes
HALE, Alice Dr. Audie M. Everett Room 308
3-25-xx Plastic surgery POD 1
Afebrile, VSS
Hemovac drainage moderate
Bilaterally some bruising. Wounds clean and
dry. Chest clear. Doing well
Plan: Continue present treatment.
Arie Brushfield
3/26/xx POD 2
Temperature 99, VSS
Hemovac drainage: Right: 76, Left 85
Wounds clean and dry
Doing well
Audie M. Everett
3/26/XX
Underwire bra on tomorrow.
Continue present treatment.
Arie Brushfield
3/27/xx POD 3
Afebrile, VSS
Wound clean and dry
Drainage minimal.
Audie M. Everett
3/24/xx Post-op orders
Procedure: right modified mastectomy
1. VS q 15 min. until stable. Then q 30 min. X 2. Then
q 1 hour X 2. Then q 4 hours X 4. Then Q routine.
2. Bed rest with head of bed elevated 30 degrees.
3. To bathroom with help.
4. Liquids PO. Resume regular diet as tolerated.
5. D/C IV once PO is tolerated.
6. Record Jackson-Pratt drainage Q 4 X 2, then Q shift
7. Ancef 1 g. IV Q 6.
8. Demerol 75 mg. IM Q 3 hours prn for pain
9. Tigan supp. Q 6 hours prn for nausea and vomiting
10. MOM 30 cc po QOD prn constipation
11. Dalmane 30 mg po QHS prn sleep
12. Stat Hhgb and Hct in recovery room
13. Hgb and Hct in am.
Audie M. Everett
3/25/xx FeSO4 300 mg po
Audie M. Everett
3/26/xx
Pt. to wear bra today.
Audie M. Everett
3/27/xx T.O. Dr. A. M. Everett / Carlye Breslin, RN Tylenol # 3 1-2 tabs po Q 3-4 hrs prn pain
Audie M. Everett
3/27/xx
Will place in bra today.
Arie Brushfield
3/28/xx POD 4
Afebrile, VSS
Wound clean and dry
Drainage minimal.
Audie M. Everett
Date/ Time
Physician Orders and Progress Notes
Orders
Sundance Medical Center Painted Valley, USA
Form # _ _ _ _
Progress Notes
HALE, Alice Dr. Audie M. Everett Room 308
3/28/xx Change pain med to Percocet 1 po Q 6 hrs prn pain.
V.O. Dr. A. M. Everett / Carlye Breslin, RN Audie M. Everett
3/29/xx Discharge in am.
Arie Brushfield
3-30-xx
Discharge. Demerol 75 mg., Vistaril now.
Audie M. Everett
3/28/xx
Left breast is shifting down slightly
Drains out in 1 to 2 more days.
Arie Brushfield
3/29/xx POD 5
Afebrile, VSS
Drainage minimal
Continue present treatment.
Audie M. Everett
3-30-xx POD 6
Afebrile
VSS
Drainage minimal
Drains removed.
Home today.
Clinic appointment in 4 days.
Audie M. Everett
Date/ Time Nursing Progress Notes
Sundance Medical Center Painted Valley, USA
Nursing Progress Notes
HALE, Alice Dr. Audie M. Everett Room 308
3-24 2:00pm Pt. received on unit via stretcher. IV infusing well. Alert and oriented. Two (2)
J-P drains intact.
Ginger Bayliss, RN
3-24 3-11:30pm Pt. alert and awake at times. Oriented to time and place. Medicated X 2 with
Demerol 75 mg. IM with relief. To bathroom with assistance. Voided 350 cc dark urine.
Tolerated well. Sleeping off and on most of shift. Vital signs stable. IV patent and infusing well
@ 100cc/hr. Skin warm and dry. Chest dressing and pressure bandage dry and intact. 2 JPs
draining moderate amounts of dark red blood. Complains of nausea X 1. Vomited approx.
200 cc clear fluid emesis. Taking po fluids well, mostly water and grapefruit juice.
Margie Cutler, RN.
3-25 11-7am VSS Dressing dry and intact. Receiving Ancef IV 1 gm. JP drains draining
moderate amount of dark red blood IV infusing well. To bathroom. Tolerated well. No
complains of nausea or vomiting. Receiving Ancef IV 1 gm.
Maggie Dish, RN
3/26 7-3pm Dressing intact. JPs draining well. Right drainage 76. Left drainage 85.
Medicated X 1 with Demerol 75 mg. with good relief. Worn bra all shift. To bathroom.
Margaret Houlihan, RN
3-27 3-11:30 VSS. Afebrile. To bathroom. Tolerated well. Lungs clear. Po intake adequate,
Appetite increasing. Bowel sounds heard. Abdomen soft. Bilateral chest dressings dry and
intact. JPs draining moderate amounts serosanguinous fluid. Medicated X 2 for pain with
Demerol 75 mg. IM with good relief.
Margie Cutler, RN.
3-28 11-7am VSS JPs draining serosanguinous fluid. Dressings dry . No complaints of pain.
Appears to have slept well. Medicated for pain x 2.
Maggie Dish, RN
3-28 7-3:30 p.m. VSS and afebrile. No complains of nausea and vomiting. Medicated X 3 for pain
with good relief. Dressings dry and intact. Ambulating well. JP draining well.
Margaret Houlihan, RN
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Date/ Time Nursing Progress Notes
Sundance Medical Center Painted Valley, USA
Nursing Progress Notes
HALE, Alice Dr. Audie M. Everett Room 308
3-28 3-11pm VSS. Afebrile. Ambulating well. Medicated X 1 for pain with Demerol 75 mg. with
good relief. Dressing dry and intact. JPs draining dark red blood. Taking diet well.
Margie Cutler, RN.
3-29 11-7 VSS Dressing dry and intact. JPs draining moderate amounts light red fluid. No
complains offered.
Maggie Dish, RN
3-29 7-3am VSS. Afebrile. JPs intact and draining left reddish drainage. Chest dressing dry and
intact. Med X 1 with Tylenol # 3 with good relief. Lungs clear. No complains.
Ginger Bayliss, RN
3-29 3-11 VSS Chest dressing removed by Dr. Incision lines clean and dry. JPs patent.
Med X 1 for pain with Percocet with good relief. Anticipate discharge tomorrow.
Margie Cutler, RN.
3-30 11-7am V.S. Medicated X 1 with Percocet with good relief. Incisions dry and intact.
Steri-strips in place. JPs patent and intact.
Maggie Dish, RN
3-31 10:30am Pt. discharged with instructions.
Ginger Bayliss, RN
Sundance HealthCare Systems Painted Valley, USA
PARENTERAL FLUID SHEET
Date Start (s) Description Amt Tube Drg Time or Add (a) (blood, plasma, D5) Site Rate Given Change Change Initials
Initials Nurse's Signature/Title Initials Nurse's Signature/Title
Nsg 2822
3/24/xx S D5 1/2 NS Rt 125 900 - - GB/ RN 0830 Forarm
1630 A D5 1/2 NS Rt FA 125 180 - - MD/RN
GB Ginger Bayliss, RN
MD Maggie Dish, RN
HALE, Alice Dr. Audie M. Everett Room 308 # 661944
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
GRAPHIC SHEET
Date _____________ _____________ _____________ _____________ Time 3 6 9 12 15 18 21 24 3 6 9 12 15 18 21 24 3 6 9 12 15 18 21 24 3 6 9 12 15 18 21 24
105 ...................................................................................................................................................
104 ...................................................................................................................................................
103 ...................................................................................................................................................
102 ...................................................................................................................................................
101 ...................................................................................................................................................
100 ...................................................................................................................................................
99 ...................................................................................................................................................
98 ...................................................................................................................................................
97 ...................................................................................................................................................
96 ...................................................................................................................................................
95 ...................................................................................................................................................
Pulse
Resp.
B/P ___/___| ___/___| ___/___ ___/___| ___/___| ___/______/___| ___/___| ___/___ ___/___| ___/___| ___/___ ___/___| ___/___| ___/___ ___/___| ___/___| ___/______/___| ___/___| ___/___ ___/___| ___/___| ___/___
Weight: ______ | _______ ______ | _______ ______ | _______ ______ | _______
In ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______ Out ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______
Diet ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______ Appetite ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______
3/25 3/26 3/27 3/28
64 62 70 72 74 76 76 78 80 78 78 76
20 20 20 16 16 18 20 18 20 18 16 18
98 60 110 70 108 68 108 64 98 60 100 68 102 62 100 60 98 60 100 70 100 68 108 60
1980 - -
248 + BR 163 85
HALE, Alice Dr. Audie M. Everett Room 308 # 661944
142 140 139 139
Reg
- - poor fair fair good fair good good good good good
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
GRAPHIC SHEET
Date _____________ _____________ _____________ _____________ Time 3 6 9 12 15 18 21 24 3 6 9 12 15 18 21 24 3 6 9 12 15 18 21 24 3 6 9 12 15 18 21 24
105 ...................................................................................................................................................
104 ...................................................................................................................................................
103 ...................................................................................................................................................
102 ...................................................................................................................................................
101 ...................................................................................................................................................
100 ...................................................................................................................................................
99 ...................................................................................................................................................
98 ...................................................................................................................................................
97 ...................................................................................................................................................
96 ...................................................................................................................................................
95 ...................................................................................................................................................
Pulse
Resp.
B/P ___/___| ___/___| ___/___ ___/___| ___/___| ___/______/___| ___/___| ___/___ ___/___| ___/___| ___/___ ___/___| ___/___| ___/___ ___/___| ___/___| ___/______/___| ___/___| ___/___ ___/___| ___/___| ___/___
Weight: ______ | _______ ______ | _______ ______ | _______ ______ | _______
In ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______ Out ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______
Diet ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______ Appetite ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______
3/29 3/30
HALE, Alice Dr. Audie M. Everett Room 308 # 661944
84 84 80 80 88 80
18 20 18 18 20 20
100 60 90 60 90 60 100 60 90 60 90 60
- -
146 180
138 137
Reg - - - -
good
Sundance HealthCare Systems Painted Valley, USA
Patient Name:
Physician:
Room No.
Activities of Daily Living:
ADL History: Date: _____/_____/_____ Time: ____:____ � Diet Problems: _________________________________________________________________
� Special Diet: _________________________________________________________________
Appetite: � Poor � Fair � Good
� Sleeping Aids: _________________________________________________________________
� Elimination Problems: ___________________________________________________________
� Bowel Pattern: _________________________________________________________________
ADL Needs Assessment: Date: _____/_____/_____ Time: ____:____ � Ambulation: _________________________________________________________________
� Eating: _________________________________________________________________
� Bathing: _________________________________________________________________
� Eliminating: _________________________________________________________________
� Turning: _________________________________________________________________
� Other: _________________________________________________________________
SYSTEM REVIEW/PROBLEM IDENTIFICATION INVENTORY: Check only if problem exists.
Level of Consciousness:
� Disoriented/Not alert:
� Confused
� Noisy
� Semi-Coma
� Comatose
Communication:
� Speech Impediment
� Aphasic
� Other ________________
Mouth:
� Oral Problem
� Dental Prosthesis
Dentures, Caps, Bridges
Urinary/Reproductive:
� Urinary Problems
� Urinary Devices
� Discharge
� Breast Problems
� Menstrual Problems
Eyes:
� Visual Problem
� Prosthesis (contacts, Glasses)
Ears:
� Hearing Problem
� Auditory Prosthesis
Cardiovascular:
� Cardiac Problem
� Cardiac Devices
� Circulatory Problem
Musculoskeletal:
� Musculoskeletal Problems
� Amputation
� Ambulatory Prostheses
Respiratory:
� Nasal Problem
� Respiratory Problem
Gastrointestinal:
� GI Problems
� Elimination Problem
� Ostomy
Psycho-Social:
� Emotional Problems
Prostheses and Valuables: _________________________________________________________ ______________________________________________________________________________
General Appearance: ____________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________Completed By/Title
Form xxxxb (10/02) nsg Nursing Admission Assessment
HALE, Alice Dr. Audie M. Everett Room 308
03 24 xx 06 45
None None Daily
Watch and rings put in safe
Healthy appearing white female somewhat anxious over the surgery
D. Brown, RN
�
�
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
To Be Completed Upon Admission: Date: _____/_____/_____ Time: ____:____ Source of Interview Data: ________________________________________
Admitted From: � Admitting � Emergency Room � L.T.C. � Other
Admitted Via: � Ambulatory � Wheelchair � Stretcher
Form xxxx (10/02) nsg
Sundance HealthCare Systems Painted Valley, USA
Nursing Admission Assessment
Patient Name:
Physician:
Room No.
Vital Signs:
Temperature: ____.___ Pulse: _______ Respirations: ________ Blood Pressure: _____/_____ Stated Stated Actual Height: ___________ Weight: _________ Weight: _________ B.M.I. __________
Orientation to Room:
S.O./Patient Verbalizes Understanding of: � Nurse Call System � Patient Information Book � Visiting Hours � Valuables Policy � Bed Controls � Shower Controls � Hospital Ed. T.V. � Telephone � Cafeteria Hours � Smoking Policy � Emergency Call Light � Lighting System � Safety Regulations
Patient Statement/Understanding of Diagnoses and/or Description of Symptoms:
Current/Past Major Illnesses Hospitalized Date Major Treatment - Operations Outcome
� Yes � No
� Yes � No
� Yes � No
� Yes � No
Allergic / Reactions Home Medications Schedule Last Dose Home Medications Schedule Last Dose Drugs
Other
� Pharmacy � Sent Home � Bed Side � Other
Skin and Body Assessment
Skin Condition Turgor � Good � Poor � Edematous Temp: � Warm/Dry � Cold � Clammy Color � Average � Pale � Cyanotic
Habit History
Tobacco Type � Snuff � Pipe � Cigar
� Chew � Cigarettes Usage: ___ Packs per day ___ No. of Years
___ Years Stopped ___ Age of First Use
Alcohol
Usage: ___ Never ___ Occasional ___ Moderate ___ Heavy
Caffeinated Beverages (per day)
___ Cups Coffee ____ Soda
Gyn History
Date of Last Pap L.M.P. ______ Smear ______ MMG: ______ Gravida ___ Para ___ AB ___ Breast Self Exam � Yes � No No. of Children Born Alive ____ Stillborn ____
HALE, Alice Dr. Audie M. Everett Room 308
03 24 xx 06 45
�
�
98 5 65 19 99 65
5' 6" 140 142
� � � � � � � � � � � � �
"I'm here to have my right breast removed and get implants on both sides"
Breast CA � 1 yr ago left mastectomy
Penicillin None
20 days 1/xx 0 0 0
X 0
X
3 1
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
MEDICATION PROFILE
Medication and Date of Order
Date
Time
Dose
Route
Init
Date
Time
Dose
Route
Init
Date
Time
Dose
Route
Init
Date
Time
Dose
Route
Init
Date
Time
Dose
Route
Init
Date
Time
Dose
Route
Init
HALE, Alice Dr. Audie M. Everett Room 308 # 661944
3-24 Vistari1 50 mg 3/24 3/24
7:30 4:00
50 50
po po
GB MC
3-25 FeSO4 300 mg po t.i.d. 3/25 3/25 3/25 3/26 3/26 3/26 3/27 3/27 3/27 3/28
with meals 6:30 11:30 5:30 6:30 11:30 5:30 6:30 11:30 5:30 6:30
300 300 300 300 300 300 300 300 300 300
po po po po po po po po po po
MD MH MC MD MH MC MD MH MC MD
3-24 Ancef 1 gm IV q.6h. 3/24
7:30
1 gm
iv MH
3-24 Demerol 75 mg 7:30am 3/24 3/24 3/26 3/26 3/27 3/27 3/28 3/27 3/29 3/29
4:00 8:30 8:00 8:00 3:50 9:58 1:15 5:15 6:30 2:30
75 75 75 75 75 75 75 75 75 75
po po po po po po po po po po
GB GB MH MC MC MC MD MD MD MH
3-28 Percocet 1 tablets p.o. 3/29
6:30
1
po
MC
3-30 Tylenol #3 2 tablets p.o. 3/29
9:00
2
po
MD
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
MEDICATION PROFILE
Medication and Date of Order
Date
Time
Dose
Route
Init
Date
Time
Dose
Route
Init
Date
Time
Dose
Route
Init
Date
Time
Dose
Route
Init
Date
Time
Dose
Route
Init
Date
Time
Dose
Route
Init
HALE, Alice Dr. Audie M. Everett Room 308 # 661944
3-25 FeSO4 300 mg po t.i.d. 3/28 3/29 3/29 3/29 3/30
with meals 11:30 5:30 6:30 11:30 5:30
300 300 300 300 300
po po po po po
MH MC MD MH MC
Patient Family Name First Name Age Room No. Hosp. No.
Attending Physician Date Lab. No.
24 Hour Urine 0 - 30 for Microalbumin
Form L-9003 (5/01) pa URINALYSIS
Sundance HealthCare Systems Painted Valley, USA
Component Normal First Second Third Fourth Date
Color Yellow
Character Clear
Spec Gravity 1.020 or less
Leukocytes Negative
Nitrates Negative
PH 5-6
Protein Urine Negative
Glucose Urine Negative
Ketones Urine Negative
Urobilinogen 0 - 1 mg/dl
Bilirubin Urine Negative
Occ Blood Urine Negative
WBC/HPF 0 - 5
RBC/HPF 0 - 5
Epitheial
Casts/LPF
Crystals
Amorphorus
Mucous
Yeast Cells Negative
Bacteria Negative
Sent for Culture: Y / N Y / N Y / N Y / N
HALE, Alice 50 308 661944
Dr. Audie M. Everett 3/24/xx # 1003-24b
Y, Cloudy
1.016
0-1
7.5
0
0
0
0
0-1
2+
1+
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Patient Family Name First Name Age Room No. Hosp. No.
Attending Physician Date Lab. No.
Form L-9003 (5/01) pa HEMATOLOGY
Sundance HealthCare Systems Painted Valley, USA
Component Normal First Second Third Fourth Date
Hematology
WBC (x 103) M/F 4.3 - 11.0
RBC (x 103) M 4.6 - 6.2
F 4.2 - 5.4
Hgb (g/dl) M 12 - 18
F 12 - 16
HCt (%) M 40 - 54
F 36 - 47
MCV (x 103) M 80 - 94
F 82 - 100
MCH (x 103) M/F 26 - 33
MCHC (%) M/F 31 - 36
PLT (x 103) M/F 150 - 375
Differential
Band 0 - 6%
Seg 46 - 82%
Lymph 13 - 37%
Mono 4 - 12%
Eosin 0 - 5%
Baso 2 - 2%
NRBC
Atyp Lymph
Meta
Myelo
Pros
Blast
HALE, Alice 50 308 661944
Dr. Audie M. Everett 3/24/xx # 1003-24a
7.5
4.42
13.2 12.8 10.8 L
38.5 38.0 31.0 L
87
29.8
34.2
1
54
40 H
5
0
03/24 03/25 3/26
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Form 9427 (8/00) mr HISTORY & PHYSICAL
Sundance HealthCare Systems Painted Valley, USA
Signature Dr.
HALE, Alice Dr. Audie M. Everett Room 308 # 661944
History of Present Illness: This 50-year-old white female was admitted for a prophylactic right mastectomy due to a positive family history of breast carcinoma. One and half years prior to this admission, the patient had a left breast mass which was biopsied and revealed a malignancy. At that time she underwent a left modified radical mastectomy. She had no radiation or chemotherapy following the mastectomy. No axillary nodes were found at that time. The patient is now admitted for a prophylactic mastectomy. Menarche was at age 12. She is a Gravida O, Parity 0, Abortus 0.
Family History: Family history is positive for carcinoma . Maternal grandmother died from breast carcinoma.
Social History: Patient is divorced with one adult son. Does not smoke. Drinks alcohol on occasion.
Allergies: Penicillin.
Medications: None.
Physical Exam: Alert white female in no acute distress. HEENT: Sclera and conjunctive are clear. Funduscopic exam shows sharp disks bilaterally with otherwise normal retina. Oral pharynx is clear. Pupils are round, equal and reactive. Neck: Supple without palpable adenopathy or thyroid enlargement. Chest: Lungs are clear to auscultation and percussion. Spine: Nontender to percussion. Breast: Status post left modified radical mastectomy. Incision well healed. No evidence or recurrence in the axillary nodes. Cardiac: Normal rate and rhythm. Abdomen: Soft and nontender without palpable masses or hepatosplenomegaly. No inguinal adenopathy. GU/rectal: Deferred. Extremities: No clubbing, cyanosis, or edema. Peripheral pulses are intact. Full range of motion. Neurologic: Alert and oriented.
Impression: Left breast carcinoma, previously resected.
Plan: Right prophylactic mastectomy with bilateral reconstruction in morning.
AEV/mk D: 3/23/xx T: 3/24/xx
Audie M. Everett
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Patient's Name
Birth Date Age
Street Address
Phone Number
Hospital Number
Sex Marital Status State Zip County
City
Patient's Occupation
Soc. Sec. #
Name
Address
Relationship
Phone No.
Responsible for Account
Religion
Date Admitted Time AM PM
Date Discharged Time AM PM
Date of Last Admission Name & Address of Any Institution From Which Discharged in Last 60 Days
Admitting Physician
Attending Physician
Consultant
Sundance HealthCare Systems Painted Valley, USA
Notify In Emergency
Room
Race
Ethnicity
Admitting Diagnosis (Within 24 Hours)
Principal Diagnosis
Secondary Diagnoses
Complications
ICD-9-CM CODES
Operative Procedures (Date & Title)
Discharged Alive ____ Died ____ Autopsy Yes ____ No ____
ADMISSION SUMMARY SHEET
Physician Signature
This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental. © 2003. American Health Information Management Association
Left breast carcinoma, previously resected, admitted for right prophylactic mastectomy with bilateral reconstruction in morning.
1. Multi-focal lobular carcinoma in situ with focal stromal invasion, right breast.
2. History of carcinoma of left breast, status post mastectomy 1-1/2 years ago. 3. Family history of breast cancer.
Hale, Alice B. 203 Cottonwood Drive # 661944
09/18/xx 50 Painted Canyon 701 453-5504
F Single N.D. 61447 Rimrock 308
536-22-4455 Lutheran W
Information Systems Manager Non-Hispanic
Trixie Norton Friend Self
203 Cottonwood Drive, Painted Canyon 701 453-8081
3/24/xx 0645 AM 03/30/xx 1130 AM
Unknown N/A
Dr. A. M. Everett Dr. A. W. Bushfield
Dr. A. M. Everett
1. Right mastectomy with bilateral breast reconstruction. 2. Left breast reconstruction with submuscular implant, right simple mastectomy followed by
submuscular implant reconstruction of the right breast.
�
Audie M. Everett
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
CONDITIONS OF ADMISSION
1. CONSENT TO HOSPITAL CARE I am presenting myself for admission to Sundance HealthCare Systems. I voluntarily consent to the rendering of medical care which is determined to be necessary or beneficial in the professional judgement of my physician. This includes routine diagnostic procedures and medical treatment by authorized agents and employees of the Hospital, and by its medical staff, or their designees.
I acknowledge that no guarantees have been made to me as to the effect of such examination or treatment on my condition.
2. AUTHORIZATION TO RELEASE INFORMATION I authorize Sundance HealthCare Systems to release such information from my medical record as may be necessary for the completion of the hospital’s or my physician’s claims for reimbursement to my insurance company or agency. I UNDERSTAND THAT DISCLOSURE MAY INCLUDE DIAGNOSES AND OPERATIONS OR PROCEDURES PER- FORMED AND THAT, AT THE REQUEST OF MY INSURANCE COMPANY OR AGENCY, MY COMPLETE MEDI- CAL RECORD MAY BE SUBJECT TO REVIEW. IN ADDITION, I UNDERSTAND THAT COPIES OF MY RECORD MAY BE OBTAINED BY MY INSURANCE COMPANY OR AGENCY.
3. ASSIGNMENT OF BENEFITS In consideration of the services received or to be received for this admission to Sundance HealthCare Systems, I assign all insurance benefits due me. I further warrant that the hospital shall be entitled to the full amount of its charges. Any credit balance resulting for any reason will be applied to other existing accounts. This also assigns benefits to Anesthesia Consultants, PC.
I hereby agree to pay any and all hospital charges that exceed or that are not covered by my hospitalization insur- ance coverage. This assignment shall be irrevocable.
4. VALUABLES DISCLAIMER I understand that Sundance HealthCare Systems maintains a safe for the safekeeping of money and valuables. I, also, understand that I assume full responsibility for any and all of my valuables, money, clothing, dentures, and other personal items while a patient in the hospital unless deposited with the Hospital for safekeeping.
Valuables Deposited with the Hospital YES NO
5. REQUEST FOR FACILITY ACCOMMODATIONS I agree to pay to the Hospital any difference between the semi-private rate provided by my hospitalization insurance and the Hospital charges for a private accommodation. I understand that private accommodations are more expen- sive than the room rate payable by my hospitalization insurance and that it is my responsibility to pay the difference.
I request a Private Room YES NO
This document has been fully explained to me, and I certify that I understand its contents and agree to it freely.
AM DATE TIME PM Patient or authorized person
Witness Relationship
Guarantor/Insured Certificate Holder
Signature is not that of the patient because: ( ) patient is a minor
( ) other reason (specify):
�
�
3/24/xx 6:45 Alice S. Hale
Marilyn Flemming
Patient's Name
Birth Date Age
Street Address
Phone Number
Hospital Number
Sex Marital Status State Zip County
City
Patient's Occupation
Soc. Sec. #
Name
Address
Relationship
Phone No.
Responsible for Account
Religion
Date Admitted Time AM PM
Date Discharged Time AM PM
Date of Last Admission Name & Address of Any Institution From Which Discharged in Last 60 Days
Admitting Physician
Attending Physician
Consultant
Sundance HealthCare Systems Painted Valley, USA
Notify In Emergency
Room
Race
Ethnicity
Admitting Diagnosis (Within 24 Hours)
Principal Diagnosis
Secondary Diagnoses
Complications
ICD-9-CM CODES
Operative Procedures (Date & Title)
Discharged Alive ____ Died ____ Autopsy Yes ____ No ____
ADMISSION SUMMARY SHEET
Physician Signature
This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental. © 2003. American Health Information Management Association
Sundance Medical Center Painted Valley, USA
DISCHARGE INSTRUCTIONS SHEET
Patient's Signature Date Time Attending Physician
a.m. p.m.
I have read the above instructions and received a copy of them. They were explained to me and all my questions were answered satisfactorily.
Instructions: Please follow the instructions given below. This is an important part of your continued recovery. If, after reading the instructions, you have any questions please ask your physician/nurse for clarification.
Diet:
Medications:
Activity:
Follow-Up:
Patient Name:
Physician:
Room No.
HALE, Alice Dr. Audie M. Everett Room 308
Regular diet as tolerated.
Audie M. EverettAlice S. Hale 3/30/xx 10:30
Percocet 1 p.o. q.4h. p.r.n. for pain.
Anspor 500 mg po q.i.d.
Ferrous sulfate 300 mg p.o. q.i.d.
No lifting (more than 10 pounds) for two weeks.
May return to work in two weeks.
Clinic appointment in three days post discharge.
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Form 9055 (3/98) him DISCHARGE SUMMARY
Sundance HealthCare Systems Painted Valley, USA HALE, Alice
Dr. Audie M. Everett Room 308 # 661944
Discharge Summary:
Date of Admssion: 3/24/xx Date of Discharge: 3/30/xx
This 50-year-old white female was admitted for a prophylactic right mastectomy due to a positive family history of breast carcinoma. One and half years prior to this admission, the patient had a left breast mass which was biopsied and revealed a malignancy. At that time she underwent a left modified radical mastectomy. She had no radiation or chemotherapy following the mastectomy. No axillary nodes were found at that time. The patient is now admitted for a prophylactic mastectomy. Menarche was at age 12. She is a Gravida O, Parity 0, Abortus 0.
Past History: Family history reveals that a grandmother died from breast carcinoma. The patient has no history of birth control pills. The patient had a tonsillectomy and adenoidectomy as a child. She is allergic to Penicillin and is not presently on any medication.
Physical Examination: The patient was afebrile and vital signs were within normal limits. HEENT was within normal limits. Chest was clear bilaterally. Breasts showed a well healed left mastectomy scar. There was no palpated evidence of axillary node recurrence. Heart was within normal limits. The abdomen is benign. Bowel sounds were normal active. Extremities were without clubbing, cyanosis or edema. Neurological examination was grossly intact.
Laboratory Data: Hematocrit 38.5, WBC 7,500. UA was in normal limits. Chest x-ray and EKG were in normal limits.
Hospital Course: On 3/25/xx the patient underwent a right simple mastectomy and bilateral breast reconstruc- tion with bilateral implants. The patient did well postoperatively. She remained afebrile. The wounds were well healed. Upon discharge, the right prosthesis was slightly firmer than the left prosthesis. On the day of discharge, the drains were removed after having minimal drainage for 48 hours and she was discharged on 3-30-xx. She was afebrile and the wounds were well healed. Discharge medications included Percocet one p.o. q.4h. p.r.n. for pain, Ancef 500 mg. p.o. q.i.d , Iron Sulfate 300 mg. p.o. t.i.d. The patient will be seen for follow-up in the clinic.
Note: Upon pulling the left Jackson Pratt drain, a small portion of the soft portion of the drain had snapped off and remained submuscular. At the time it was decided the drain as well as the implant were sterile and probably would cause not harm.
AEV/mk D: 3/31/xx T: 4/01/xx
Audie M. Everett
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Patient Name Attn Phys Room MR #
Pre-Anesthesia Visit by:
Prior Anesthesia � Yes � No
If yes, complications? � Yes � No
If yes, specify:
� EKG � Chest X-ray
Vital Signs: Temp. ____ Pulse ____
Resp. ____ B.P. ____/____
Height ____ ft ____ in Weight _____ lbs
Smoker � Yes � No
Jaundice � Yes � No
Anesthesia Risk: 1 2 3 4 5
Normal Other System Inventory:
� � Mental/Emotional Status:
� � Skin
� � Respiratory Asthma COPD
� � Cardiovascular.
� � Musculoskeletal:
� � Gastrointestinal
� � Genitourinary
� � Neurological
� � EENT
Sundance HealthCare Systems Painted Valley, USA
Pre-Anesthesia Record
Anesthesia Record:
Date/Times
O2
N2O
220
200
180
160
140
120
100
80
60
40
20X R
es p
� P
ul se
� B
.P .
� B
.P .
A ge
n ts
: F
lu id
s: Blood Lost Given
______
Form 4377 (8/03) ad ANESTHESIA RECORD
Date
Operation
Surgeon
Assistant
Transfer
Anesthetists:
Anesthesia: � General Duration: � Spinal ______ Start � Epidural ______ Stop � Local
Agents:
HALE, Alice Dr. Audie M.
Everett Room 308 # 661944
John Dundee U
U
U
97.5 62 18 124 82
5 7 142 U
U
U
U
U
U
U
U
U
U
U
3/24/xx
Rt Mod mastectomy, immediate recon
A. M. Everett, A. Brushfield
John Dundee U
8:50 a 11:30 a
Premeds of Demerol and Vistaril
Morphine,
Pentothal,
Anectine
8:50 9 930 10 1030 11 1130 12
62 31 2 2 2 2
4 4 4 4 4 4
5 2 3 2 2 2 2
300
80
2 units PRC's Allergies - PNC S/P Left mastectomy
90 24 255 445 495 510 5100
Lact/Ringers: 1000 2900
� � �
� � � �
�� �� �� �� ��
�� �� �� �� ��
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������������
���
������ ���
� � �
��� ��� ����������
Temp 36 36 35
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Form 9784 (3/98) mr OPERATIVE RECORD
Surgeon
Assistant
Operation
Anesthesia
Preoperative Diagnosis
Postoperative Diagnosis
Signature Dr.
Sundance HealthCare Systems Painted Valley, USA
HALE, Alice Dr. Arie Brushfield Room 308 # 661944
Dr. A. Brushfield
: Left breast reconstruction with submuscular implant, right simple mastectomy followed by submuscular implant reconstruction of the right breast.
General with endotracheal intubation
Status post left modified radical mastectomy
Status post left modified radical mastectomy
Complications: None.
After the induction of general anesthesia and endotracheal intubation with the patient in the supine position, the anterior chest was prepped with pHisoHex and water in a sterile fashion. After Dr. Everett performed the simple mastectomy on the right side, the Plastic Surgery team then proceeded to perform bilateral reconstruc- tions. On the left side, an incision was made in the lateral aspect of the previous mastectomy scar, extending down to the underlying muscle. A submuscular pocket was developed at the level of the ribs, the pectoralis major, serratus anterior and rectus abdominis. A 460/500 cc double lumen round mammary prosthesis was then placed within this pocket. The muscle was closed with interrupted 000 Vicryl stitches to the muscle and facial layers, the subcutaneous and dermal layers were reapproximated with interrupted 0000 Vicryl stitches and the skin was reapproximated with running subcuticular stitches of 000 nylon. Attention was then turned to the right breast where a simple mastectomy had been performed. An incision was made along the fifth rib at the level of the pectoralis major. A submuscular pocket was developed using the pectoralis major, serratus anterior and rectus abdominis. A 320/360 cc. mammary double lumen implant was then placed within this pocket, the muscle as reapproximated with interrupted 000 Vicryl stitches. The skin was the reapproximated with interrupted 000 Vicryl stitches to the dermal layer and a running subcuticular stitch and the subcutaneous pockets, exiting through separate stab wounds in the right axilla. A Jackson-Pratt drain was also placed within the left submuscular pocket. These were of 0000 nylon to the skin. Prior to closure on this side, a Jackson- Pratt drain was placed within the submuscular sutured to the skin with 00 silk stitches. At the termination of the procedure, adequate breast symmetry was noted to have been achieved. The patient was then placed in a dressing to maintain the implants in a position. The patient tolerated this procedure well, left the Operating Room and was received in the Recovery Room in satisfactory condition.
AB/mk D: 3/24/xx T: 3/25/xx
Arie Brushfield
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
