Medical Coding
cwwmlrchall06
him215_final_project---PATIENTRECORD.doc|
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Global Care Medical Center100 Main St, Alfred NY 14802(607) 555-1234Hospital No. 999 |
Inpatient Face Sheet |
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Patient Name and Address |
Gender |
Race |
Marital Status |
Patient No. |
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PIRE, SALLY 1122 CHERRY STREET ALMOND, NY 14804 |
F |
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S |
IPCase005 |
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Date of Birth |
Age |
Maiden Name |
Occupation |
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06/23/YYYY |
60 |
NA |
Dog groomer |
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Admission Date |
Time |
Discharge Date |
Time |
Length of Stay |
Telephone Number |
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07/31/YYYY |
0950 |
08/05/YYYY |
1150 |
07 DAYS |
(607)000-4397 |
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Guarantor Name and Address |
Next Of Kin Name and Address |
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PIRE, SALLY 1122 CHERRY STREET ALMOND, NY 14804 |
PIRE, JACOB 556 MILL STREET ALMOND, NY 14804 |
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Guarantor Telephone No. |
Relationship to Patient |
Next of Kin Telephone Number |
Relationship to Patient |
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(607)000-4397 |
Self |
(607)555-7676 |
BROTHER |
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Admitting Physician |
Service |
Admit Type |
Room Number/Bed |
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John Black, MD |
NA |
NA |
0253 |
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Attending Physician |
Admitting Diagnosis |
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John Black, MD |
Acute and chronic alcoholism |
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Primary Insurer |
Policy and Group Number |
Secondary Insurer |
Policy and Group Number |
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New Age Insurance |
PW 6790456 |
NEBC |
229162171 |
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Diagnoses and Procedures |
ICD Code |
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Principal Diagnosis |
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Acute and chronic alcoholism |
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Secondary Diagnoses |
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Principal Procedure |
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Secondary Procedures |
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Discharge Instructions |
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Activity: ( Bed rest ( Light ( Usual ( Unlimited (Other: As tolerated. |
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Diet: ( Regular ( Low Cholesterol ( Low Salt ( ADA ( _____ Calorie |
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Follow-Up: (Call for appointment ( Office appointment on ( Other: N/A |
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Special Instructions: |
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Attending Physician Authentication: |
Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 7/31/YYYY 10:00:00 AM EST) |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Consent To Admission |
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I, |
Sally Pire |
hereby consent to admission to the Global Care Medical Center (ASMC) , and I further consent to such |
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routine hospital care, diagnostic procedures, and medical treatment that the medical and professional staff of ASMC may deem necessary or advisable. I authorize the use of medical information obtained about me as specified above and the disclosure of such information to my referring physician(s). This form has been fully explained to me, and I understand its contents. I further understand that no guarantees have been made to me as to the results of treatments or examinations done at the ASMC. |
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Reviewed and Approved: Sally Pire ATP-B-S:02:1001261385: Sally Pire (Signed: 07/31/YYYY 10:12:05 AM EST) |
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Signature of Patient |
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Signature of Parent/Legal Guardian for Minor |
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Relationship to Minor |
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Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 07/31/YYYY 10:12:05 AM EST |
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WITNESS: Global Care Medical Center Staff Member |
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Consent To Release Information For Reimbursement Purposes |
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In order to permit reimbursement, upon request, the Global Care Medical Center (ASMC) may disclose such treatment information pertaining to my hospitalization to any corporation, organization, or agent thereof, which is, or may be liable under contract to the ASMC or to me, or to any of my family members or other person, for payment of all or part of the ASMC’s charges for services rendered to me (e.g. the patient’s health insurance carrier). I understand that the purpose of any release of information is to facilitate reimbursement for services rendered. In addition, in the event that my health insurance program includes utilization review of services provided during this admission, I authorize ASMC to release information as is necessary to permit the review. This authorization will expire once the reimbursement for services rendered is complete. |
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Reviewed and Approved: Sally Pire ATP-B-S:02:1001261385: Sally Pire (Signed: 07/31/YYYY 10:14:17 AM EST) |
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Signature of Patient |
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Signature of Parent/Legal Guardian for Minor |
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Relationship to Minor |
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Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 07/31/YYYY 10:16:24 AM EST |
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WITNESS: Global Care Medical Center Staff Member |
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Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Advance Directive |
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Your answers to the following questions will assist your Physician and the Hospital to respect your wishes regarding your medical care. This information will become a part of your medical record. |
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Yes |
No |
Patient’s Initials |
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1. Have you been provided with a copy of the information called “Patient Rights Regarding Health Care Decision?” |
X |
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2. Have you prepared a “Living Will?” If yes, please provide the Hospital with a copy for your medical record. |
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X |
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3. Have you prepared a Durable Power of Attorney for Health Care? If yes, please provide the Hospital with a copy for your medical record. |
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X |
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4. Have you provided this facility with an Advance Directive on a prior admission and is it still in effect? If yes, Admitting Office to contact Medical Records to obtain a copy for the medical record. |
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X |
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5. Do you desire to execute a Living Will/Durable Power of Attorney? If yes, refer to in order: a. Physician b. Social Service c. Volunteer Service |
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X |
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Hospital Staff Directions: Check when each step is completed. |
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1. |
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Verify the above questions where answered and actions taken where required. |
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2. |
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If the “Patient Rights” information was provided to someone other than the patient, state reason: |
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Name of Individual Receiving Information |
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Relationship to Patient |
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3. |
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If information was provided in a language other than English, specify language and method. |
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4. |
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Verify patient was advised on how to obtain additional information on Advance Directives. |
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5. |
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Verify the Patient/Family Member/Legal Representative was asked to provide the Hospital with a copy of the Advanced Directive which will be retained in the medical record. |
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File this form in the medical record, and give a copy to the patient. |
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Name of Patient Name of Individual giving information if different from Patient |
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Reviewed and Approved: Sally Pire ATP-B-S:02:1001261385: Sally Pire (Signed: 07/31/YYYY 10:35:05 AM EST) |
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Signature of Patient |
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Date |
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Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 07/31/YYYY 10:35:47 AM EST |
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Signature of Hospital Representative |
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Date |
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Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Discharge Summary |
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ADMISSION DATE: 07/31/YYYY DISCHARGE DATE: 08/05/YYYY ADMISSION DIAGNOSIS: Acute and chronic alcoholism. DISCHARGE DIAGNOSIS: Acute and chronic alcoholism. SUMMARY: This is a 60 year-old female who had had extensive workups recently because of an abnormal CAT scan of the abdomen. She had been in our hospital previously earlier this year, had had the scan done in Rochester. Had a repeat scan done at General. Finally she was sent to Dr. Miller at Strong, for further evaluation. Apparently his study was unremarkable. Since that period of time, we’ve lost track of her. Apparently she had some problems with alcoholism recently, ended up at the Snowy Owls Retreat in Florida because of her alcohol problems, and they, for some reason or other, felt that she should be transferred here. I’m not exactly sure why. She, in the interval time, had sustained a fracture of her left forearm and wrist. This is being cared for by Dr. Jones in Rochester. She’s returning to see him in follow up about that situation. Her brief workup here included a chest x-ray which showed no evidence of any active pulmonary disease. There was noted a compression deformity of the lower thoracic spine representing old fractures. X-ray of the left wrist revealed a healing comminuted fracture of the distal radius, position alignment of fracture fragments in wrist joint appeared to be satisfactory. Her lab work included an alkaline phosphatase of 20, blood sugar 143, sodium 144, potassium 4.4, carbon dioxide 27, chloride 108, cholesterol 143, Serum glutamic oxalacetic transaminase 48, Lactate dehydrogenase 310, creatinine 0.4, calcium 9.0, phosphorus 2.5, bilirubin 0.8, total protein 6.2, albumin 3.6, uric acid 2.7, Urine with a specific gravity of 1.005, albumin and sugar were negative. White count was 5,800, hemoglobin 13.4, hematocrit 39.3, segmented cells 49, lymphocytes 34, monocytes 12, eosinophils 4, and 1 band cell. She was treated supportively here in the hospital. She developed no problems, no signs of delirium tremens. She was up, ambulatory, doing well and eating well. She is discharged at this time on no medications, other than Theragram M, 1 tablet twice a day.
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DD: 07/31YYYY |
Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/31/YYYY 05:44:18 PM EST) |
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DT: 08/02/YYYY |
Physician Name |
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Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
History & Physical Exam |
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ADMISSION DIAGNOSIS: Alcoholism, probably acute and chronic. CHIEF COMPLAINT: Weak and referred over by Strong Hospital. HISTORY OF PRESENT ILLNESS: This is a 60-year-old female who has had extensive workup and evaluation recently because of abnormal liver function studies. She was in this hospital in January where she manifested mildly abnormal liver function studies without definitive diagnosis. She had had a past history of splenectomy and hypokalemia. She was discharged after workup for this evaluation and was sent to Strong Hospital in Rochester for scan of the abdomen. They were somewhat unsure about the scan at that time, but in light of her history, they reported it as normal. However, a repeat scan was done down at General where the study was reported as significantly abnormal, but without a specific diagnosis. Ultimately, she was referred to Dr. Miller at Strong, who did extensive studies, and apparently felt there was no acute process. During all of this time she denied any significant alcoholic intake, although we have been told otherwise by certain members of her family. In the past month to six weeks, I’m not sure what has happened. Apparently she tried to go back to work but was unable to. Subsequent to that she was in an altercation where she sustained a fracture of the left wrist. Subsequent to that she ended up at the Snowy Owls Treatment Center in Florida and apparently they felt that she needed further hospitalization here from physical point of view for further stabilization. PAST MEDICAL HISTORY: Pretty well explained in the above outline. In addition, she has had a splenectomy several years ago for an abnormal bleeding problem. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She works as a licensed practical nurse type worker in a nursing home. She claims to be a nonsmoker and did claim to be a nondrinker, but we are quite sure now that she has had a rather heavy alcohol intake. SYSTEMIC REVIEW: No cough, dyspnea, orthopnea on exertion. Appetite is good. No bowel or bladder problems. VITAL SIGNS: Weight 113, Blood pressure 150/90, Pulse 80, Temperature 97. SKIN: Warm and dry. Color good. GENERAL: Clear. Eyes – pupils round, react and equal. Extraocular muscles are okay. Sclera clear; no evidence of any jaundice. Nose and throat are unremarkable. Hydration is adequate. NECK: Supple, No nodes or thyroid abnormalities. CHEST: Peripheral lung fields are clear. HEART: Sounds are good. No significant murmurs are heard. BREASTS: Free of masses. ABDOMEN: No palpable megaly or masses. Well-healed scar in the left upper quadrant area. PELVIC & RECTAL: Not done at this time. EXTREMITIES: Warm, pulses good. NEUROLOGIC & ORTHOPEDIC: Are okay.
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DD: 07/31/YYYY |
Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/31/YYYY 06:05:44 PM EST) |
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DT: 08/02/YYYY |
Physician Name |
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Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Progress Notes |
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Date |
Time |
Physician’s signature required for each order. (Please skip one line between dates.) |
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07/31/ YYYY |
1050 |
CHIEF COMPLAINT: DIAGNOSIS: Acute and chronic alcoholism. PLAN OF TREATMENT: Alert alcohol treatment counseling staff about need for treatment. DISCHARGE PLAN: Home. No services needed Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/31/YYYY 10:44:32 AM EST) |
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07/31/YYYY
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1100 |
Workup in progress. Apparent difficulty with alcoholism. Patient history a bit sketchy. Working diagnosis as stated. Possible cirrhosis. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/31/YYYY 11:04:32 AM EST) |
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07/31/YYYY |
1115 |
Recent wrist fracture; will ask Surgery to follow. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/31/YYYY 11:17:30 AM EST) |
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08/01/YYYY
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1000 |
No sign of delirium tremens. Appetite good. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 08/01/YYYY 10:07:00 AM EST) |
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08/03/YYYY |
1000 |
Doing well. Home Wednesday. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 08/03/YYYY 10:05:07 AM EST) |
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08/04/YYYY
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0930 |
Home Wednesday. Doing well. No further follow up indicated. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 08/04/YYYY 09:44:32 AM EST) |
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Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Doctors’ Orders |
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Date |
Time |
Physician’s signature required for each order. (Please skip one line between dates.) |
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07-31-YYYY |
1100 |
Complete blood count Urinalysis Lytes SCG II Chest X ray Regular diet Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/31/YYYY 11:03:12 AM EST) |
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07/31/YYYY |
1115 |
Watch for delirium tremens. Repeat x-ray hand and wrist – left. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/31/YYYY 11:18:44 AM EST) |
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07/31/YYYY |
1130 |
Surgical consult – Dr. Taylor for fracture of arm. Valium 5 milligrams daily for nervousness Thiamine 100 milligrams intramuscular Theragram M 1 tab twice a day History and physical exam dictated. Surgical consult – regarding recent fracture of left wrist. Tylenol 1 or 2 tablets every 4-6 hours as needed for pain. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/31/YYYY 11:38:00 AM EST) |
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08/01/YYYY |
1100 |
May ambulate as desired. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 08/01/YYYY 11:02:12 AM EST) |
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08/05/YYYY |
1100 |
Discharge today. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 08/05/YYYY 11:12:56 AM EST) |
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Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Radiology Report |
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Date of X-ray: 07/31/YYYY REASON: Repeat x-ray. TECHNICAL DATA: RADIOLOGIST’S CONSULTATION REPORT 07/31/YYYY LEFT WRIST: Posteroanterior, oblique and lateral views taken through plaster show a comminuted fracture of the distal radius. The position and alignment of the fracture fragments and of the wrist joint appear to be satisfactory. LEFT HAND: Multiple views of the left hand show only the previously described fracture of the distal radius.
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DD: 07/31/YYYY |
Reviewed and Approved: Randall Cunningham MD ATP-B-S:02:1001261385: Randall Cunningham MD (Signed:07/31/YYYY 02:24:44 PM EST) |
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DT: 08/01/YYYY |
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Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Radiology Report |
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Date of X-ray: 07/31/YYYY REASON: Cirrhosis. TECHNICAL DATA: 07/31/YYYY CHEST: Posteroanterior and lateral views show that the cardiothoracic ratio measures 13.8/26.2 cm. The pulmonary vascularity is normal, and there is no evidence of any active pulmonary disease. There is a compression deformity of the lower thoracic spine which appears to represent an old compression fracture.
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DD: 07/31/YYYY |
Reviewed and Approved: Randall Cunningham MD ATP-B-S:02:1001261385: Randall Cunningham MD (Signed:07/31/YYYY 02:32:08 PM EST) |
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DT: 08/01/YYYY |
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Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Laboratory Data |
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SPECIMEN COLLECTED: IN: |
07/31YYYY 1242 |
SPECIMEN RECEIVED OUT: |
07/31/YYYY 1810 |
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BLOOD CHEMISTRY 1 |
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Test |
Reference |
Result |
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ACID PHOSPHATASE |
0.0-0.8 U/I |
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ALKALINE PHOSPHATASE |
50-136 U/I |
10.0 |
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AMYLASE |
23-85 U/I |
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LIPASE |
4-24 U/I |
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GLUCOSE FASTING |
70-110 mg/dl |
143 |
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GLUCOSE |
Time collected |
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BUN |
7-22 mg/dl |
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SODIUM |
136-147 mEq/1 |
144 |
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POTASSIUM |
3.7-5.1 mEq/l |
4.4 |
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CARBON DIOXIDE |
24-32 mEq/l |
27 |
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CHLORIDE |
98-108 mEq/l |
108 |
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CHOLESTEROL |
120-280 mg/dl |
143 |
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SERUM GLUTAMATE PYRUVATE TRANSAMINASE
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3-36 U/I |
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SERUM GLUTAMIC OXALOCETIC TRANSAMINASE |
M-27-47 U/I |
F-22-37 U/I |
48 |
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CREATININE KINASE |
M-35-232 U/I |
F-21-215 U/I |
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LACTATE DEHYDROGENASE |
100-190 U/I |
310 |
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CREATININE |
M-0.8-1.3 mg/dl |
F-0.6-1.0 mg/dl |
0.4 |
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CALCIUM |
8.7-10.2 mg/dl |
9.0 |
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PHOSPHORUS |
2.5-4.9 mg/dl |
2.5 |
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BILIRUBIN-DIRECT |
0.0-0.4 mg/dl |
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BILIRUBIN-TOTAL |
Less than 1.5 mg/dl |
0.8 |
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TOTAL PROTEIN |
6.4-8.2 g/dl |
6.2 |
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ALBUMIN |
3.4-5.0 g/dl |
3.6 |
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URIC ACID |
M-3.8-7.1 mg/dl |
F-2.6-5.6 mg/dl |
2.7 |
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TRIGLYCERIDE |
30-200 mg/dl |
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U/I = International Units g/dl = grams per deciliter mEq = millequivalent per deciliter mg/dl = milligrams per deciliter |
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Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Laboratory Data |
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Specimen Collected: |
07/31//YYYY |
Specimen Received: |
07/31/YYYY |
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Test |
Result |
Flag |
Reference |
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URINALYSIS |
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DIPSTICK ONLY |
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COLOR |
straw |
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SP GRAVITY |
1.005 |
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( 1.030 |
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ALBUMIN |
negative |
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( 125 mg/dl |
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BILIRUBIN |
negative |
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( 0.8 mg/dl |
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SUGAR |
negative |
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( 10 mg/dl |
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BLOOD |
negative |
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0.06 mg/dl hgb |
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PH |
6.5 |
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5-8.0 |
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ACETONE |
negative |
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( 30 mg/dl |
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UROBILINOGEN |
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( -1 mg/dl |
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NITRITES |
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NEG |
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LEUKOCYTE |
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( 15 WBC/hpf |
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W.B.C. |
rare |
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( 5/hpf |
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R.B.C. |
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( 5/hpf |
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BACT. |
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1+(( 20/hpf) |
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URINE PREGNANCY TEST |
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***End of Report***
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Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Laboratory Data |
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TIME IN: |
07/31/YYYY 1241 |
TIME OUT: |
07/31/YYYY 1604 |
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COMPLETE BLOOD COUNTS DIFFERENTIAL |
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Test |
Result |
Flag |
Reference |
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WHITE BLOOD CELL |
5.8 |
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4.5-11.0 thou/ul |
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RED BLOOD CELL |
4.07 |
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5.2-5.4 milliliter/ upper limit |
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HEMOGLOBIN |
13.4 |
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11.7-16.1 grams per deciliter |
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HEMATOCRIT |
39.3 |
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35.0-47.0 % |
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MEAN CORPUSCULAR VOLUME |
96.4 |
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85-99 factor level |
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MEAN CORPUSCULAR HEMOGLOBIN |
32.8 |
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MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION |
34.0 |
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33-37 |
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RED CELL DISTRIBUTION WIDTH |
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11.4-14.5 |
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PLATELETS |
145 |
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130-400 thou/ul |
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SEGMENTED CELLS % |
49 |
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|
LYMPHOCYTES % |
34 |
|
20.5-51.1 |
|
MONOCYTES % |
12 |
|
1.7-9.3 |
|
EOSINOPHILS % |
4 |
|
|
|
|
|
|
|
|
BAND CELLS % |
1 |
|
|
|
|
|
|
|
|
|
|
|
|
|
Thou/ul= thousand upper limit
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
***End of Report*** |
|||
|
Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
|
PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Graphic Chart |
|||||||||||||||||||||||
|
DAY IN HOSPITAL |
1 |
2 |
3 |
4 |
|||||||||||||||||||||
|
DATE |
07/31/YYYY |
08/01/YYYY |
08/02/YYYY |
08/03/YYYY |
|||||||||||||||||||||
|
PULSE (•) |
TEMP (X) |
0400 |
0800 |
1200 |
1600 |
2000 |
2400 |
0400 |
0800 |
1200 |
1600 |
2000 |
2400 |
0400 |
0800 |
1200 |
1600 |
2000 |
2400 |
0400 |
0800 |
1200 |
1600 |
2000 |
2400 |
|
140 |
106 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
130 |
105 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
120 |
104 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
110 |
103 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
100 |
102 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
90 |
101 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
80 |
100 |
|
|
X |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
70 |
99 |
|
|
|
|
|
|
|
|
( |
|
|
|
|
|
|
|
|
|
|
( |
|
( |
|
|
|
60 |
98.6 |
|
|
( |
|
|
|
|
|
|
|
|
|
|
( |
|
|
|
( |
|
|
|
|
|
|
|
50 |
98 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
40 |
97 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
30 |
96 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
20 |
95 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
RESPIRATION |
|
|
20 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
BLOOD PRESSURE |
0800 |
|
1600 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||
|
|
1200 |
150/100 |
2000 |
|
|
140/86 |
|
|
|
132/80 |
|
|
|
118/80 |
|
|
|||||||||
|
WEIGHT |
113# |
|
|
|
|||||||||||||||||||||
|
DIET |
Regular |
|
|
|
|||||||||||||||||||||
|
APPETITE |
|
90% |
|
|
|
|
|
|
|
|
|
|
|||||||||||||
|
BATH |
Self |
|
|
|
|||||||||||||||||||||
|
INTAKE/OUTPUT |
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||
|
INTAKE |
ORAL FLUIDS |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
IV FLUIDS |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
BLOOD |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
8 HOUR TOTAL |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
24 HOUR TOTAL |
|
|
|
|
||||||||||||||||||||
|
OUTPUT |
URINE |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
STOOL |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
EMESIS |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
N-G |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
8 HOUR TOTAL |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
24 HOUR TOTAL |
|
|
|
|
||||||||||||||||||||
|
|
|||||||||||||||||||||||||
|
Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
|
PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Graphic Chart |
|||||||||||||||||||||||
|
DAY IN HOSPITAL |
4 |
5 |
|
|
|||||||||||||||||||||
|
DATE |
08/04/YYYY |
08/05/YYYY |
|
|
|||||||||||||||||||||
|
PULSE (•) |
TEMP (X) |
0400 |
0800 |
1200 |
1600 |
2000 |
2400 |
0400 |
0800 |
1200 |
1600 |
2000 |
2400 |
0400 |
0800 |
1200 |
1600 |
2000 |
2400 |
0400 |
0800 |
1200 |
1600 |
2000 |
2400 |
|
140 |
106 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
130 |
105 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
120 |
104 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
110 |
103 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
100 |
102 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
90 |
101 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
80 |
100 |
|
|
X |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
70 |
99 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
60 |
98.6 |
|
|
( |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
50 |
98 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
40 |
97 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
30 |
96 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
20 |
95 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
RESPIRATION |
|
|
20 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
BLOOD PRESSURE |
0800 |
|
1600 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||
|
|
1200 |
150/100 |
2000 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||
|
WEIGHT |
113# |
|
|
|
|||||||||||||||||||||
|
DIET |
Regular |
|
|
|
|||||||||||||||||||||
|
APPETITE |
|
90% |
|
|
|
|
|
|
|
|
|
|
|||||||||||||
|
BATH |
Self |
|
|
|
|||||||||||||||||||||
|
INTAKE/OUTPUT |
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||
|
INTAKE |
ORAL FLUIDS |
X |
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
IV FLUIDS |
0 |
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
BLOOD |
0 |
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
|
0 |
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
8 HOUR TOTAL |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
24 HOUR TOTAL |
|
|
|
|
||||||||||||||||||||
|
OUTPUT |
URINE |
X |
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
STOOL |
0 |
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
EMESIS |
1 |
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
N-G |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
8 HOUR TOTAL |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
24 HOUR TOTAL |
|
|
|
|
||||||||||||||||||||
|
|
|||||||||||||||||||||||||
|
Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
|
PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Medication Administration Record |
|||||||||
|
|
|||||||||||
|
Special Instructions: Allergic to Sulfa / Demerol |
|||||||||||
|
|
|||||||||||
|
Medication (dose and route) |
Date: 07/31 |
|
Date: 08/01 |
|
Date: 08/02 |
|
Date: 08/03 |
||||
|
|
Time |
Initials |
|
Time |
Initials |
|
Time |
initials |
|
Time |
Initials |
|
Theragram M 1 tablet twice a day. |
0800 |
---- |
|
0800 |
JD |
|
0800 |
JD |
|
0800 |
JD |
|
|
1600 |
OR |
|
1600 |
OR |
|
1600 |
OR |
|
1600 |
OR |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Single Orders & Pre-Ops |
|
|
|
|
|
|
|
|
|
|
|
|
Thiamine 100 milligrams intramuscular |
1800 |
OR |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PRN Medications: |
|
|
|
|
|
|
|
|
|
|
|
|
Valium 5 milligrams daily as needed for nerves |
2200 |
OR |
|
2000 |
OR |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Tylenol 1 or 2 tablets every 4-6 hours as needed for pain |
1800 |
OR |
|
2400 |
JD |
|
0130 |
JD |
|
0800 |
JD |
|
|
|
|
|
0800 |
VS |
|
0815 |
VS |
|
|
|
|
|
|
|
|
1200 |
VS |
|
2000 |
OR |
|
|
|
|
|
|
|
|
1600 |
OR |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||
|
|
|||||||||||
|
Initials |
Signature and Title |
|
Initials |
Signature and Title |
|
Initials |
Signature and Title |
||||
VT |
Vera South, RN |
|
GPW |
G. P. Well, RN |
|
|
|
||||
|
OR |
Ora Richards, RN |
|
PS |
P. Small, RN |
|
|
|
||||
|
JD |
Jane Dobbs, RN |
|
|
|
|
|
|
||||
|
HF |
H. Figgs, RN |
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
||||
|
Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
|
PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Medication Administration Record |
|||||||||
|
|
|||||||||||
|
Special Instructions: Allergic to Sulfa / Demerol |
|||||||||||
|
|
|||||||||||
|
Medication (dose and route) |
Date: 08/04 |
|
Date: 08/05 |
|
Date: 00/00 |
|
Date: 00/00 |
||||
|
|
Time |
Initials |
|
Time |
Initials |
|
Time |
initials |
|
Time |
Initials |
|
Theragram M 1 tablet twice a day. |
0800 |
VS |
|
0800 |
VS |
|
|
|
|
|
|
|
|
1600 |
OR |
|
1600 |
OR |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Single Orders & Pre-Ops |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
|
|
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|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PRN Medications: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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Tylenol 1 or 2 tablets every 4-6 hours as needed for pain |
0630 |
JD |
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0800 |
VS |
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1015 |
VS |
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Initials |
Signature and Title |
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Initials |
Signature and Title |
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Initials |
Signature and Title |
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VT |
Vera South, RN |
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GPW |
G. P. Well, RN |
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OR |
Ora Richards, RN |
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PS |
P. Small, RN |
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JD |
Jane Dobbs, RN |
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HF |
H. Figgs, RN |
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Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Nurses’ Notes |
|||||||
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DATE |
TIME |
TREATMENTS & MEDICATIONS |
TIME |
NURSES’ NOTES |
|||||
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07/31/YYYY |
|
Friday |
1030 |
Admission of 60-year-old white female with fractured left wrist with cast on but it has been split the full length because of edema. Done by doctor. Patient having large amount of pain. Patient requests to see a dentist here at the hospital because of having so many problems with them. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/31/YYYY 10:31:03 AM EST) |
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07/31/YYYY |
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1200 |
Regular diet taken and retained. Appetite good. Still complains of pain in left arm. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/31/YYYY 12:07:41 PM EST) |
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1500 |
Dr. Black in to examine the patient. New orders noted. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/31/YYYY 03:02:28 PM EST) |
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07/31/YYYY |
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1600 |
To x-ray and returned. Complains of pain in left arm. Resting. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/31/YYYY 04:16:03 PM EST) |
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1800 |
Diet taken fair. Resting. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/31/YYYY 06:10:44 PM EST) |
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2000 |
98.6 – 100-20 140/90 |
2000 |
Resting. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/31/YYYY 08:04:00 PM EST) |
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2040 |
Tylenol 1 tablet |
2100 |
Bedtime care given. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 09/11/YYYY 09:02:41 PM EST) |
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2200 |
Valium 5 milligrams |
2200 |
Resting. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 09/11/YYYY 10:05:10 PM EST) |
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Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Nurses’ Notes |
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DATE |
TIME |
TREATMENTS & MEDICATIONS |
TIME |
NURSES’ NOTES |
|||||
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08/01/YYYY |
11-7 |
Saturday Tylenol 1 tablet |
2400 |
Complains of pain. Medicated with Tylenol 1 tablet. Left arm elevated on a pillow. Hand warm to touch. Color good. Good blanching. States “It feels prickly.” No numbness. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 08/01/YYYY 12:03:16 AM EST) |
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0300 |
Continues to sleep. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 08/01/YYYY 03:02:44 AM EST) |
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0600 |
Slept at long intervals. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 08/01/YYYY 06:05:07 AM EST) |
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08/01/YYYY |
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97.7 76-20 140/86 |
0730 |
Awake. Fingers warm and pink on left hand. Ambulated to bathroom. Returned to bed. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 08/01/YYYY 07:32:41 AM EST) |
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Dr. Black in. |
0800 |
Breakfast taken well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/01/YYYY 08:02:30 AM EST) |
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0900 |
Dr. in 0930. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/01/YYYY 09:05:10 AM EST) |
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1000 |
Ambulated in hall to tub room. Self morning care with assistance. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/01/YYYY 10:02:50 AM EST) |
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1030 |
Returned to room. Out of bed in chair. Morning spent napping on bed. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/01/YYYY 10:32:00 AM EST) |
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1215 |
Lunch taken well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/01/YYYY 12:16:00 PM EST) |
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1330 |
Afternoon spent resting/napping at intervals. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/01/YYYY 01:32:00 PM EST) |
|||||
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Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
|||||||||
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Nurses’ Notes |
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DATE |
TIME |
TREATMENTS & MEDICATIONS |
TIME |
NURSES’ NOTES |
|||||
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08/01/YYYY |
1511 |
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1530 |
Patient resting quietly with left arm elevated on a pillow. Complains of pain in her left lower arm. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/01/YYYY 03:32:00 PM EST) |
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1630 |
Out of bed in chair for dinner. Ambulated well by self. Ambulated in hall twice and tolerated well. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/01/YYYY 04:33:00 PM EST) |
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1715 |
Appetite was good. . Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/01/YYYY 05:12:00 PM EST) |
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1830-1930 |
Visitors in to see. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/01/YYYY 07:31:03 PM EST) |
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2000 |
Back to bed and watching television. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/01/YYYY 08:07:41 PM EST) |
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2030 |
Refused bedtime care. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/01/YYYY 08:32:28 PM EST) |
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2200 |
Patient stated her arm felt better since it had been taped earlier in the afternoon. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/01/YYYY 10:00:03 PM EST) |
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2230 |
Resting quietly with eyes closed. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/01/YYYY 10:32:44 PM EST) |
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08/02/YYYY |
11-7 |
Sunday |
2400 |
Awake resting with eyes closed. Cast on left wrist. Hand warm to touch. Color good. Patient stated that arm feels “prickly.” Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 08/02/YYYY 12:04:00 AM EST) |
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Tylenol 2 tablets |
0130 |
Complains of arm pain. Given Tylenol 2 tablets. Reviewed and Approved: J. Dobbs , RN ATP-B-S:02:1001261385: J. Dobbs , RN (Signed: 08/02/YYYY 01:33:10 AM EST) |
|||||
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Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
|||||||||
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Nurses’ Notes |
|||||||
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DATE |
TIME |
TREATMENTS & MEDICATIONS |
TIME |
NURSES’ NOTES |
|||||
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0300 |
Appears to be sleeping. Reviewed and Approved: J. Dobbs , RN ATP-B-S:02:1001261385: J. Dobbs , RN (Signed: 08/02/YYYY 03:00:00 AM EST) |
|||||
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0600 |
Remains asleep. Left arm elevated on a pillow. Hand warm and color good. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs , RN (Signed: 08/02/YYYY 06:32:41 AM EST) |
|||||
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08/02/YYYY |
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98 – 68 20 132/86 |
0730 |
Awake. Ambulated to bathroom as needed. Cast intact. Fingers warm and pink. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South , RN (Signed: 08/02/YYYY 07:37:11 AM EST) |
|||||
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|
0800 |
Breakfast taken well. Ambulated to tub room. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/02/YYYY 08:2:00 AM EST) |
|||||
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0830 |
Self care done. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/02/YYYY 08:32:00 AM EST) |
|||||
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0900 |
Morning spent watching television and reading without complaints. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/02/YYYY 09:04:20 AM EST) |
|||||
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|
Dr. Black is in. |
1215 |
Lunch taken well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/02/YYYY 12:16:00 PM EST)
|
|||||
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1300 |
Afternoon spent visiting and watching television without complaints. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/02/YYYY 01:06:34 PM EST) |
|||||
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08/02/YYYY |
|
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1600 |
Up walking in hall without complaints. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/02/YYYY 04:03:00 PM EST |
|||||
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1800 |
Diet taken well. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/02/YYYY 06:00:00 PM EST) |
|||||
|
Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
|||||||||
|
PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Nurses’ Notes |
|||||||
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DATE |
TIME |
TREATMENTS & MEDICATIONS |
TIME |
NURSES’ NOTES |
|||||
|
|
2000 |
99.2 96 – 20 150/90 |
2000 |
Bedtime snack. Visiting with roommate. Self bedtime care. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/02/YYYY 08:02:49 PM EST) |
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2200 |
Resting. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/02/YYYY 10:07:13 PM EST) |
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08/03/YYYY |
11-7 |
Monday |
2400 |
Appears to be sleeping. Left arm elevated on a pillow. Hand warm and pink. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 08/03/YYYY 12:04:00 AM EST |
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0300 |
Continues to sleep. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 08/03/YYYY 03:03:45 AM EST |
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0600 |
Remains asleep. Respirations easy. Left hand elevated on a pillow. Fingers warm and pink. No complaints offered. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 08/03/YYYY 06:04:20 AM EST |
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08/03/YYYY |
|
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0730 |
Awake and out of bed as desired. To shower for self morning care. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385:V. South, RN (Signed: 08/03/YYYY 07:33:12 AM EST |
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0800 |
Appetite good. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/03/YYYY 08:06:50 AM EST) |
|||||
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|
|
|
1000 |
Comfortable without complaints at present. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/03/YYYY 10:03:34 AM EST) |
|||||
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1200 |
Appetite good. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385:V. South, RN (Signed: 08/03/YYYY 12:05:00 PM EST |
|||||
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1430 |
Comfortable without complaints at present. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385:V. South, RN (Signed: 08/03/YYYY 02:33:10 PM EST) |
|||||
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|||||
|
Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
|||||||||
|
PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Nurses’ Notes |
|||||||
|
DATE |
TIME |
TREATMENTS & MEDICATIONS |
TIME |
NURSES’ NOTES |
|||||
|
08/03/YYYY |
3-11 |
Monday |
1530-1630 |
Resting quietly. No complaints offered. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/03/YYYY 04:32:49 PM EST) |
|||||
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1700 |
Appetite good at supper. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/03/YYYY 05:07:13 PM EST) |
|||||
|
|
|
99.1- 84- 18 118/78 |
1830-1930 |
Vital signs taken; sitting up watching television and visiting with roommate. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/03/YYYY 06:37:23 PM EST) |
|||||
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|
|
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2030 |
Bedtime care given; snack taken well. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/03/YYYY 08:32:00 PM EST) |
|||||
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2200 |
Quiet; no complaints. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/03/YYYY 10:02:00 PM EST) |
|||||
|
08/04/YYYY |
11-7 |
Tuesday |
2400 |
Appears to be sleeping. Respirations easy. Reviewed and Approved: J. Dodds, RN ATP-B-S:02:1001261385: J. Dodds, RN (Signed: 08/04/YYYY 12:04:20 AM EST) |
|||||
|
|
|
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0300 |
Continues to sleep. Reviewed and Approved: J. Dodds, RN ATP-B-S:02:1001261385: J. Dodds, RN (Signed: 08/04/YYYY 03:06:47 AM EST) |
|||||
|
|
|
|
0600 |
Left hand in cast elevated on a pillow. Hand warm. Color good. Reviewed and Approved: J. Dodds, RN ATP-B-S:02:1001261385: J. Dodds, RN (Signed: 08/04/YYYY 06:02:17 AM EST) |
|||||
|
08/04/YYYY |
|
|
0730 |
Awake and out of bed as desired. Tub bath taken. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/04/YYYY 07:33:10 AM EST |
|||||
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0800 |
Appetite good. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/04/YYYY 08:02:00 AM EST) |
|||||
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|||||
|
Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
|||||||||
|
PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Nurses’ Notes |
|||||||
|
DATE |
TIME |
TREATMENTS & MEDICATIONS |
TIME |
NURSES’ NOTES |
|||||
|
|
|
|
1000 |
Out of bed as desired. Walking in hall. Cast patent. No complaints offered. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/04/YYYY 10:04:49 AM EST) |
|||||
|
|
|
|
1200 |
Appetite good. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/04/YYYY 12:01:13 PM EST) |
|||||
|
|
|
|
1430 |
Comfortable without complaints at present. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/04/YYYY 02:33:18 PM EST) |
|||||
|
08/04/YYYY |
|
|
1530 |
Resting quietly. No complaints offered. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/04/YYYY 04:31:55 PM EST) |
|||||
|
|
|
|
1700 |
Appetite good at supper. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/04/YYYY 05:01:09 PM EST) |
|||||
|
|
|
|
1830 |
Comfortable. Sitting up watching television and visiting with roommate. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/04/YYYY 06:31:44 PM EST) |
|||||
|
|
|
|
2030 |
Bedtime care given; snack taken well. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 08/04/YYYY 08:32:11 PM EST) |
|||||
|
08/04/YYYY |
2330 |
Tuesday |
2330 |
Appears to be sleeping soundly. Reviewed and Approved: J. Dodds, RN ATP-B-S:02:1001261385: J. Dodds, RN (Signed: 08/04/YYYY 11:36:34 PM EST) |
|||||
|
08/05/YYYY |
|
Wednesday |
0100 |
Continues to sleep soundly. Reviewed and Approved: J. Dodds, RN ATP-B-S:02:1001261385: J. Dodds, RN (Signed: 08/05/YYYY 01:03:00 AM EST |
|||||
|
|
|
|
0230 |
Remains asleep. Reviewed and Approved: J. Dodds, RN ATP-B-S:02:1001261385: J. Dodds, RN (Signed: 08/05/YYYY 02:32:17 AM EST) |
|||||
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|||||
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|||||
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|||||
|
Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
|||||||||
|
PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Nurses’ Notes |
|||||||
|
DATE |
TIME |
TREATMENTS & MEDICATIONS |
TIME |
NURSES’ NOTES |
|||||
|
|
|
|
0400 |
Sleeping. Reviewed and Approved: J. Dodds, RN ATP-B-S:02:1001261385: J. Dodds, RN (Signed: 08/05/YYYY 04:02:49 AM EST) |
|||||
|
|
|
|
0630 |
Had good night. Slept. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/05/YYYY 06:33:56 AM EST) |
|||||
|
08/05/YYYY |
7-3 |
|
0730 |
Awake and alert without distress. voices no complaints. Self morning care done. Showered. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/05/YYYY 07:31:14 AM EST) |
|||||
|
|
|
|
0830 |
Diet taken and tolerated well. Ambulating in hallway. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/05/YYYY 08:33:57 AM EST) |
|||||
|
|
|
|
1030 |
Ready to go home. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/05/YYYY 10:33:45 AM EST) |
|||||
|
|
|
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1145 |
Discharged to front lobby. To home with family. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/05/YYYY 11:47:23 AM EST) |
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Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Nursing Discharge Status Summary |
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1. |
AFEBRILE: |
X |
Yes |
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No |
140/80 98 – 80 - 20 |
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2. |
WOUND: |
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Clean/Dry |
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Reddened |
Infected |
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NA X |
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3. |
PAIN FREE: |
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Yes |
X |
No |
If “No,” describe: Requires Tylenol as needed. |
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4. |
POST-HOSPITAL INSTRUCTION SHEET GIVEN TO PATIENT/FAMILY: |
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Yes |
X |
No |
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If NO, complete lines 5-8 below. |
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5. |
DIET: |
X |
Regular |
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Other (Describe): |
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6. |
ACTIVITY: |
X |
Normal |
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Light |
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Limited |
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Bed rest |
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7. |
MEDICATIONS: |
None |
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8. |
INSTRUCTIONS GIVEN TO PATIENT/FAMILY: |
As ordered by Dr. Black |
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9. |
PATIENT/FAMILY verbalize understanding of instructions: |
X |
Yes |
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No |
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10. |
DISCHARGED at |
1145 |
Via: |
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Wheelchair |
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Stretcher |
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Ambulance Co. |
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X |
Ambulatory |
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Accompanied by: |
Vera South, RN |
to |
Front lobby |
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COMMENTS: |
To front lobby. Ambulated with assistant to home with family. |
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Cast on left arm. |
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DATE: |
08/05/YYYY |
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SIGNATURE: |
Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 08/05/YYYY 11:47:15 AM EST |
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Global Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
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PIRE, SALLY IPCase005 Dr. BLACK |
Admission: 07/31/YYYY DOB: 06/23/YYYY ROOM: 0253 |
Patient Property Record |
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I understand that while the facility will be responsible for items deposited in the safe, I must be responsible for all items retained by me at the bedside. (Dentures kept the bedside will be labeled, but the facility cannot assure responsibility for them.) I also recognize that the hospital cannot be held responsible for items brought in to me after this form has been completed and signed. |
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Reviewed and Approved: Sally Pire ATP-B-S:02:1001261385: Sally Pire (Signed: 07/31/YYYY 10:35:05 AM EST) |
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07/31/YYYY |
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Signature of Patient |
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Date |
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Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 07/31/YYYY 10:37:22 AM EST |
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07/31/YYYY |
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Signature of Witness |
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Date |
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I have no money or valuables that I wish to deposit for safekeeping. I do not hold the facility responsible for any other money or valuables that I am retaining or will have brought in to me. I have been advised that it is recommended that I retain no more than $5.00 at the bedside. |
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Reviewed and Approved: Sally Pire ATP-B-S:02:1001261385: Sally Pire (Signed: 07/31/YYYY 10:35:05 AM EST) |
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07/31/YYYY |
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Signature of Patient |
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Date |
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Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 07/31/YYYY 10:39:38 AM EST |
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07/31/YYYY |
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Signature of Witness |
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Date |
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I have deposited valuables in the facility safe. The envelope number is . |
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Signature of Patient |
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Date |
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Signature of Person Accepting Property |
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Date |
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I understand that medications I have brought to the facility will be handled as recommended by my physician. This may include storage, disposal, or administration. |
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Signature of Patient |
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Date |
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Signature of Witness |
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Date |
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Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234 |
