SweetStudy (HomeworkMarket.com)
  • chat0

final_project_patient_file

Is there anything else you׳d like to ask?
Our top-rated tutors can help you.

Click here to post a question
Related Documents
1 / 37100%
1 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
Hospital No. 999
INPATIENT FACE SHEET
Patient Name and Address
Gender
Race
Marital Status
Patient No.
PIRE, SALLY
1122 CHERRY STREET
ALMOND, NY 14804
F
W
S
IPCase006
Date of Birth
Maiden
Name
Occupation
06/23/YYYY
NA
Nurses’
Aide
Admission Date
Time
Discharge Date
Time
Length of Stay
Telephone Number
06-30-YYYY
12:45
07-07-YYYY
10:00
05 DAYS
(607)000-4397
Guarantor Name and Address
Next Of Kin Name and Address
PIRE, SALLY
1122 CHERRY STREET
ALMOND, NY 14804
PIRE, JACOB
556 MILL STREET
ALMOND, NY 14804
Guarantor Telephone No.
Relationship to Patient
Next of Kin Telephone Number
Relationship to Patient
(607) 000-4397
Self
(607)555-7676
BROTHER
Admitting Physician
Service
Admit Type
Room Number/Bed
John Black, MD
ME
NA
0371
Attending Physician
Admitting Diagnosis
John Black, MD
Bacterial pneumonia
Primary Insurer
Policy and Group Number
Secondary Insurer
Policy and Group Number
New Age Insurance
PW 6790456
NEBC
229162171
Diagnoses and Procedures
ICD Code
Principal Diagnosis
Bacterial Pneumonia
Secondary Diagnoses
Arteriosclerotic cardiovascular disease
Principal Procedure
Secondary Procedures
Discharge Instructions
Activity: Bed rest Light Usual Unlimited Other: As tolerated.
Diet: Regular Low Cholesterol Low Salt ADA _____ Calorie
Follow-Up: Call for appointment Office appointment on 07-14 Other:
Special Instructions:
Attending Physician Authentication:
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 01:00:00 PM EST)
2 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
CONSENT TO ADMISSION
I,
Sally Pire
hereby consent to admission to the Global Care Medical Center (ASMC) , and I further consent to
such
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.
Reviewed and Approved: Sally Pire
ATP-B-S:02:1001261385: Sally Pire
(Signed: 06/30/YYYY 01:45:05 PM EST)
Signature of Patient
Signature of Parent/Legal Guardian for Minor
Relationship to Minor
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 06/30/YYYY 01:45:05 PM EST)
WITNESS: Global Care Medical Center Staff Member
CONSENT TO RELEASE INFORMATION FOR REIMBURSEMENT PURPOSES
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.
Reviewed and Approved: Sally Pire
ATP-B-S:02:1001261385: Sally Pire
(Signed: 06/30/YYYY 01:47:05 PM EST)
Signature of Patient
Signature of Parent/Legal Guardian for Minor
Relationship to Minor
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 06/30/YYYY 01:48:05 PM EST)
WITNESS: Global Care Medical Center Staff Member
3 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
ADVANCE DIRECTIVE
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.
YES
NO
PATIENT’S INITIALS
1. Have you been provided with a copy of the information called
“Patient Rights Regarding Health Care Decision?”
X
2. Have you prepared a “Living Will?” If yes, please provide the
Hospital with a copy for your medical record.
X
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.
X
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.
X
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
X
HOSPITAL STAFF DIRECTIONS: Check when each step is completed.
1.
Verify the above questions where answered and actions taken where required.
2.
If the “Patient Rights” information was provided to someone other than the patient, state reason:
Name of Individual Receiving Information
Relationship to Patient
3.
If information was provided in a language other than English, specify language and method.
4.
Verify patient was advised on how to obtain additional information on Advance Directives.
5.
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.
File this form in the medical record, and give a copy to the patient.
Name of Patient Name of Individual giving information if different from Patient
Reviewed and Approved: Sally Pire
ATP-B-S:02:1001261385: Sally Pire
(Signed: 06/30/YYYY 01:48:05 PM EST)
Signature of Patient
Date
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 06/30/YYYY 01:49:05 PM EST)
4 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
Signature of Hospital Representative
Date
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
PATIENT HISTORY
PROBLEMS: 1. Arteriosclerotic cardiovascular disease; 2. Past history of alcoholism; 3.
Past history of hypokalemia; 4. Past history of gastritis.
MEDICATIONS: Lanoxin 0.125 milligrams a day
Lasix 20 milligrams a day
Klotrix tablets 1 tablet three times daily
PAST MEDICAL HISTORY: Patient has had some problems with alcohol in the past and a
history of gastritis due to excessive alcohol intake. She had a fractured wrist last year
potentially a secondary injury due to excessive inebriation. She also has recently been
put on Lanoxin and Lasix, apparently for arteriosclerotic cardiovascular problems, as she
experienced mild angina. Subsequent to her second admission in YYYY, she was referred to
General Hospital for further evaluation and treatment of her abnormal liver function
studies. It was determined at that time that she did not have an active process.
ALLERGY TO ASPIRIN
FAMILY HISTORY: History of alcoholism on mother’s side and cardiovascular disease on
father’s side. Brother has had heart attack related to coronary artery disease.
SOCIAL HISTORY: She works as a nurse’s aide. She’s a moderate smoker. Denies heavy
drinking, but we are not quite sure about that.
DD: 06/30/YYYY
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 06:05:44 PM EST)
DT: 07/01/YYYY
Physician Name
5 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
DISCHARGE SUMMARY
ADMISSION DATE: 06/30/YYYY DISCHARGE DATE: 07/07/YYYY
ADMISSION DIAGNOSIS: 1. Viral pneumonia; 2. Arteriosclerotic cardiovascular
disease; 3. Past history of alcoholism; 4. Past history of hypokalemia; 5. Past
history of gastritis.
DISCHARGE DIAGNOSES: Pneumonia. Arteriosclerotic cardiovascular disease.
SUMMARY: This is a 61-year-old white female who has been doing fairly well
recently until the onset of an upper respiratory infection with a cough,
recurrent chills, sweats, fever. She tried to work, was unable to. Her
temperature went to 102. Abdominal x-ray showed a pneumonia, and I felt that she
should be admitted for further evaluation and treatment.
Work-up has included a chest x-ray which revealed a small area of infiltrate in
the lingular of the right side compatible with an acute pneumonia; a follow-up
study is suggested. Repeat chest x-ray showed bilateral pneumonia, clearing;
however, there was a remaining area of consolidation in the lateral portion of
the middle lobe. Her urine showed a specific gravity of 1.015, albumin and sugar
were negative, white blood cells rare, red blood cells 0-6. White count 15,000.
Hemoglobin 11.8, hematocrit 34.8, segmented cells 52, lymphocytes 18, monocytes
12, eosinophils 3, and 5 band cells. Complete blood count was normal. Sodium 137,
potassium 3.4, carbon dioxide 27, chloride 97, alkaline phosphatase 10.4, blood
sugar 81, cholesterol 138, Serum glutamic oxalacetic transaminase 42, Lactate
dehydrogenase 260, creatinine 0.4, calcium 8.3, phosphorus 2.2, bilirubin 1.2,
total protein 6.1, albumin 3.2, uric acid 0.5. Sputum culture grew out a 1+
enterobacter. Cardiogram was reported as showing sinus tachycardia; this later
slowed down clinically.
She was started originally on Ampicillin 500 milligrams, four times a day,
Intermittent positive pressure breathing. She was continued on her Lanoxin 0.125
a day, Lasix 20 milligrams a day, Klotrix tablets 1 tablet three times a day. Her
temperature stayed up, her Ampicillin was stopped, and she was switched to
Enalapril 500 milligrams, four times a day. Now her temperature has been normal
for 48 hours. She feels better, and her cough has lessened. She is up ambulatory,
and she is anxious to go home. She is being discharged at this time on E-Mycin
333 milligrams, three times a day and Afrin nasal spray. She will continue on her
Lanoxin 0.125 milligrams a day, Lasix 20 milligrams a day, and should be seen in
follow-up in the office early next week.
DD: 06/30YYYY
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 05:44:18 PM EST)
DT: 07/01/YYYY
Physician Name
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
6 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
CURRENT VISIT & PHYSICAL
EXAM
ADMISSION DIAGNOSIS: 1. Bacterial pneumonia; 2. Arteriosclerotic cardiovascular disease;
3. Past history of alcoholism; 4. Past history of hypokalemia; 5. Past history of
gastritis.
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 60-year-old female who has been in the hospital on
two occasions within the past year or two. Her last admission was related to some
problems with alcohol. Prior to that she had been in with some abnormal liver function
studies that were later evaluated at Strong. Recently she’s been doing fairly well until
a few days ago when she had the onset of upper respiratory symptoms. She continued to
work. She now is coughing, having chills, fever, and sweats. She was seen and evaluated
in the office this morning. She had fever of 102. We referred her over for a chest x-ray
which showed pneumonia of the left lung field, and she subsequently was admitted for
further investigation, evaluation, and treatment.
FAMILY HISTORY: History of alcoholism on mother’s side and cardiovascular disease on
father’s side. Brother has had heart attack related to coronary artery disease.
SOCIAL HISTORY: She works as a nurse’s aide. She’s a moderate smoker. Denies heavy
drinking, but we are not quite sure about that.
REVIEW OF SYSTEMS: She has hacking cough, slight dyspnea on exertion, 2 pillow orthopnea,
no hemoptysis. Appetite has been fair. She denies any specific bowel or bladder
symptomatology.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 102. Pulse 90, Respirations 24.
SKIN: Warm, dry.
EYES: pupils round, reactive and equal. Extraocular muscles intact. Sclera clear; no
evidence of any jaundice. Nose and throat are unremarkable.
NECK: Supple. No nodes or thyroid abnormalities.
CHEST: Scattered rales and rhonchi at both mid-lung fields. HEART: Sounds are somewhat
distant. No significant murmurs are heard. BREASTS: Soft and free of masses.
ABDOMEN: No palpable organomegaly or masses. No tenderness or bruits. Bowel sounds
normally active.
PELVIC: Not done. RECTAL: Not done.
EXTREMITIES: Warm, pulses good.
NEUROLOGIC: Okay.
DD: 06/30/YYYY
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 06:05:44 PM EST)
DT: 07/01/YYYY
Physician Name
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
7 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
PROGRESS NOTES
Date
Time
Physician’s signature required for each order. (Please skip one line between dates.)
06/30/YYYY
1300
CHIEF COMPLAINT: Shortness of breath.
DIAGNOSIS: 1) Pneumonia. 2) Arteriosclerotic
cardiovascular disease.
Confirmed _______ Provisional __X___
PLAN OF TREATMENT: Admit for evaluation and
treatment.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 01:47:02 PM EST)
06/30/YYYY
1800
Intermittent positive pressure breathing ordered four
times a day and saline for 48 hours. Started at 1730.
Patient tolerated well. Slight production with cough,
sputum clear in color.
Reviewed and Approved: Rose Markam, CPT
ATP-B-S:02:1001261385: Rose Markam, CPT
(Signed: 06/30/YYYY 06:07:22 PM EST)
07/01/YYYY
0800
Intermittent positive pressure breathing treatment
given at 0700. Non-productive cough noted.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/01/YYYY 08:17:30 AM EST)
07/01/YYYY
1000
Intermittent positive pressure breathing treatment
given at 1000. Tolerated well.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/01/YYYY 10:06:00 AM EST)
07/01/YYYY
1300
Intermittent positive pressure breathing treatment given
at 1300. Good treatment.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/01/YYYY 01:17:30 PM EST)
8 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
9 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
PROGRESS NOTES
Date
Time
Physician’s signature required for each order. (Please skip one line between dates.)
07/01/YYYY
1600
Intermittent positive pressure breathing treatment given
at 1600. Tolerated well.
Reviewed and Approved: Rose Markam, CPT
ATP-B-S:02:1001261385: Rose Markam, CPT
(Signed: 07/01/YYYY 04:10:30 PM EST)
07/01/YYYY
1900
Still feels “lousy.” Temperature up.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/01/YYYY 07:07:42 PM EST)
07/02/YYYY
1000
Intermittent positive pressure breathing treatment not
given at 0700. Therapist busy in Intensive Care Unit. 1000
tolerated.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/02/YYYY 10:06:00 AM EST)
07/02/YYYY
1300
Intermittent positive pressure breathing treatment given.
Some production.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/02/YYYY 01:17:30 PM EST)
07/02/YYYY
1600
Intermittent positive pressure breathing treatment given
at 1600. Tolerated.
Reviewed and Approved: Rose Markam, CPT
ATP-B-S:02:1001261385: Rose Markam, CPT
(Signed: 07/02/YYYY 04:06:00 PM EST)
07/02/YYYY
1900
Hydration good. Not much appetite.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/02/YYYY 07:07:42 PM EST)
07/03/YYYY
0800
Temperature still up. Will switch to Erythromycin. Still
ambulatory as tolerated.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/03/YYYY 08:07:42 AM EST)
10 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
PROGRESS NOTES
Date
Time
Physician’s signature required for each order. (Please skip one line between dates.)
07/03/YYYY
1030
Intermittent positive pressure breathing treatment with
normal saline four times a day for 48 hours started at
1030. Tolerated well. No cough noted.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/03/YYYY 10:36:00 AM EST)
07/03/YYYY
1300
Intermittent positive pressure breathing treatment at
1300. Tolerated well.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/03/YYYY 01:06:45 PM EST)
07/03/YYYY
1700
Intermittent positive pressure breathing treatment at
1700. Tolerated well.
Reviewed and Approved: Rose Markam, CPT
ATP-B-S:02:1001261385: Rose Markam, CPT
(Signed: 07/03/YYYY 05:03:00 PM EST)
07/04/YYYY
0700
Feels better. Temperature coming down.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/04/YYYY 07:02:30 AM EST)
07/04/YYYY
0700
Intermittent positive pressure breathing treatment at
0700. Tolerated well. No cough.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/04/YYYY 07:06:45 AM EST)
07/04/YYYY
1000
Intermittent positive pressure breathing treatment at
1000. Tolerated.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/04/YYYY 10:02:17 AM EST)
07/04/YYYY
1300
Intermittent positive pressure breathing treatment at 1300.
Tolerated well. No cough.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
11 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
(Signed: 07/04/YYYY 01:06:45 PM EST)
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
12 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
PROGRESS NOTES
Date
Time
Physician’s signature required for each order. (Please skip one line between dates.)
07/04/YYYY
1800
Intermittent positive pressure breathing treatment at
1800. Tolerated well. No cough.
Reviewed and Approved: Rose Markam, CPT
ATP-B-S:02:1001261385: Rose Markam, CPT
(Signed: 07/04/YYYY 06:01:25 PM EST)
07/05/YYYY
0700
Intermittent positive pressure breathing treatment at
0700. Tolerated well. Dry cough released completion of 48
hours.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/05/YYYY 07:07:45 AM EST)
07/05/YYYY
0800
Dry cough. Fever down. Improving with intermittent
positive pressure breathing treatments. Serous otitis left
ear.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/05/YYYY 08:02:30 AM EST)
07/06/YYYY
0800
Afebrile. Regaining strength. Home tomorrow if chest x-ray
warrants.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/06/YYYY 08:06:45 AM EST)
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
13 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
14 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
DOCTORS’ ORDERS
Date
Time
Physician’s signature required for each order. (Please skip one line between dates.)
06-30-YYYY
1530
Complete blood count
Urinalysis
Chest X-ray done as outpatient. Get report.
Electrocardiogram
SCG II
Electrolytes
Sputum for culture and sensitivity
Regular diet
Aspirin, 650 milligrams every four hours for elevated
temperature
Bed rest with bathroom privileges
Intermittent positive pressure breathing with saline four
times a day for 48 hours
Ampicillin 500 milligrams four times a day for 7 days
History and physical exam dictated.
Lanoxin, 0.125 milligram daily
Lasix, 20 milligrams daily
Klotrix one tablet three times a day
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 03:33:12 PM EST)
07/01/YYYY
1115
Tylenol one or two tablets every four to six hours as needed
for fever.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/01/YYYY 11:18:44 AM EST)
07/01/YYYY
1515
Dalmane 15 milligrams every bedtime as needed for sleep.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/01/YYYY 03:20:00 PM EST)
07/03/YYYY
0930
Discontinue Ampicillin. Erythromycin 500 milligrams every six
hours for 5 days.
Intermittent positive pressure breathing with saline four
times a day for 48 hours
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/03/YYYY 09:32:12 AM EST)
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
15 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
DOCTORS’ ORDERS
Date
Time
Physician’s signature required for each order. (Please skip one line between dates.)
07/04/YYYY
0800
Chest X-ray and Complete blood count scheduled for 07/05.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/04/YYYY 08:05:23 AM EST)
07/05/YYYY
1330
Dimetapp extentabs one tablet now then twice daily.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/05/YYYY 03:40:44 PM EST)
07/06/YYYY
1515
Afrin nasal spray – 2 squeezes in each nostril every 12 hours.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/06/YYYY 03:20:00 PM EST)
07/07/YYYY
0900
Discharge.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/07/YYYY 09:02:12 AM EST)
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
16 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
RADIOLOGY REPORT
Date of X-ray: 07/05/YYYY
REASON: Pneumonia
TECHNICAL DATA: Posteroanterior and lateral.
CHEST: Posteroanterior and lateral views reveal partial clearing of the
lingular pneumonia since 06/30/YYYY. There is now an area of consolidation
In the lateral portion of the middle lobe. The lungs otherwise appear
clear.
CONCLUSION: Bilateral bacterial pneumonia.
DD: 07/05/YYYY
DT: 07/06/YYYY
Reviewed and Approved: Randall Cunningham MD
ATP-B-S:02:1001261385: Randall Cunningham MD
(Signed:07/05/YYYY 02:24:44 PM EST)
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
17 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
RADIOLOGY REPORT
Date of X-ray: 06/30/YYYY
REASON: Rule out pneumonia.
TECHNICAL DATA: Please call.
06/30/YYYY
CHEST: Posteroanterior and lateral views reveal a small area of infiltrate
in the lingual. This would be compatible with an acute pneumonia and a
follow-up study is suggested. The heart is of normal size and the lungs
otherwise appear clear. There is an old fracture in the lower thoracic
spine and several old healing left rib fractures.
DD: 06/30/YYYY
DT: 07/01/YYYY
Reviewed and Approved: Randall Cunningham MD
ATP-B-S:02:1001261385: Randall Cunningham MD
(Signed:06/30/YYYY 02:32:08 PM EST)
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
18 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
LABORATORY DATA
SPECIMEN COLLECTED:
IN:
06/30YYYY
1614
SPECIMEN RECEIVED
OUT:
06/30/YYYY
1749
BLOOD CHEMISTRY 1
TEST
REFERENCE
RESULT
ACID PHOSPHATASE
0.0-0.8 U/I
ALKALINE PHOSPHATASE
50-136 U/I
AMYLASE
23-85 U/I
LIPASE
4-24 U/I
GLUCOSE FASTING
70-110 mg/dl
GLUCOSE
Time collected
BUN
7-22 mg/dl
SODIUM
136-147 mEq/1
137
POTASSIUM
3.7-5.1 mEq/l
**3.4**
CARBON DIOXIDE
24-32 mEq/l
27
CHLORIDE
98-108 mEq/l
97
CHOLESTEROL
120-280 mg/dl
SERUM GLUTAMATE
PYRUVATE TRANSAMINASE
3-36 U/I
SERUM GLUTAMIC
OXALOCETIC
TRANSAMINASE
M-27-47 U/I
F-22-37 U/I
CREATININE KINASE
M-35-232 U/I
F-21-215 U/I
LACTATE DEHYDROGENASE
100-190 U/I
CREATININE
M-0.8-1.3 mg/dl
F-0.6-1.0 mg/dl
CALCIUM
8.7-10.2 mg/dl
PHOSPHORUS
2.5-4.9 mg/dl
BILIRUBIN-DIRECT
0.0-0.4 mg/dl
BILIRUBIN-TOTAL
Less than 1.5 mg/dl
TOTAL PROTEIN
6.4-8.2 g/dl
ALBUMIN
3.4-5.0 g/dl
URIC ACID
M-3.8-7.1 mg/dl
F-2.6-5.6 mg/dl
TRIGLYCERIDE
30-200 mg/dl
U/I = International Units
g/dl = grams per deciliter
mEq = millequivalent per deciliter
mg/dl = milligrams per deciliter
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
19 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
20 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
LABORATORY DATA
SPECIMEN COLLECTED:
IN:
06/30YYYY
2322
SPECIMEN RECEIVED
OUT:
07/01/YYYY
1032
BLOOD CHEMISTRY 1
TEST
REFERENCE
RESULT
ACID PHOSPHATASE
0.0-0.8 U/I
ALKALINE PHOSPHATASE
50-136 U/I
**10.4**
AMYLASE
23-85 U/I
LIPASE
4-24 U/I
GLUCOSE FASTING
70-110 mg/dl
81
GLUCOSE
Time collected
BUN
7-22 mg/dl
SODIUM
136-147 mEq/1
POTASSIUM
3.7-5.1 mEq/l
CARBON DIOXIDE
24-32 mEq/l
CHLORIDE
98-108 mEq/l
CHOLESTEROL
120-280 mg/dl
138
SERUM GLUTAMATE
PYRUVATE TRANSAMINASE
3-36 U/I
SERUM GLUTAMIC OXALOCETIC
TRANSAMINASE
M-27-47 U/I
F-22-37 U/I
42
CREATININE KINASE
M-35-232 U/I
F-21-215 U/I
LACTATE DEHYDROGENASE
100-190 U/I
**260**
CREATININE
M-0.8-1.3 mg/dl
F-0.6-1.0 mg/dl
**0.4**
CALCIUM
8.7-10.2 mg/dl
**8.3**
PHOSPHORUS
2.5-4.9 mg/dl
**2.2**
BILIRUBIN-DIRECT
0.0-0.4 mg/dl
BILIRUBIN-TOTAL
Less than 1.5 mg/dl
1.2
TOTAL PROTEIN
6.4-8.2 g/dl
**6.1**
ALBUMIN
3.4-5.0 g/dl
**3.2**
URIC ACID
M-3.8-7.1 mg/dl
F-2.6-5.6 mg/dl
**0.5**
TRIGLYCERIDE
30-200 mg/dl
U/I = International Units
g/dl = grams per deciliter
mEq = millequivalent per deciliter
mg/dl = milligrams per deciliter
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
21 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
LABORATORY DATA
SPECIMEN COLLECTED:
06/30/YYYY
SPECIMEN RECEIVED:
06/30/YYYY
TEST
RESULT
FLAG
REFERENCE
URINALYSIS
DIPSTICK ONLY
COLOR
Yellow clear
SP GRAVITY
1.005
1.030
ALBUMIN
negative
125 mg/dl
BILIRUBIN
negative
0.8 mg/dl
SUGAR
negative
10 mg/dl
BLOOD
moderate
0.06 mg/dl hgb
PH
7.5
5-8.0
ACETONE
negative
30 mg/dl
UROBILINOGEN
-1 mg/dl
NITRITES
NEG
LEUKOCYTE
15 WBC/hpf
W.B.C.
rare
5/hpf
R.B.C.
0-6/hpf
5/hpf
BACT.
1+( 20/hpf)
URINE PREGNANCY TEST
***End of Report***
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
22 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
LABORATORY DATA
TIME IN:
06/30/YYYY 1614
TIME OUT:
06/30/YYYY 1749
COMPLETE BLOOD COUNTS DIFFERENTIAL
TEST
RESULT
FLAG
REFERENCE
WHITE BLOOD CELL
15.1
4.5-11.0 thou/ul
RED BLOOD CELL
3.69
5.2-5.4 milliliter/ upper
limit
HEMOGLOBIN
11.8
11.7-16.1 grams per
deciliter
HEMATOCRIT
34.8
35.0-47.0 %
MEAN CORPUSCULAR
VOLUME
94.3
85-99 factor level
MEAN CORPUSCULAR
HEMOGLOBIN
32.1
MEAN CORPUSCULAR
HEMOGLOBIN
CONCENTRATION
34.0
33-37
RED CELL
DISTRIBUTION WIDTH
11.4-14.5
PLATELETS
143
130-400 thou/ul
SEGMENTED CELLS %
62
LYMPHOCYTES %
18
20.5-51.1
MONOCYTES %
12
1.7-9.3
EOSINOPHILS %
3
BAND CELLS %
5
Thou/ul= thousand upper limit
COMMENTS:
Few target cells
***End of Report***
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
23 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
LABORATORY DATA
TIME IN:
07/04/YYYY 1052
TIME OUT:
07/05/YYYY 1029
COMPLETE BLOOD COUNTS DIFFERENTIAL
TEST
RESULT
FLAG
REFERENCE
WHITE BLOOD CELL
4.9
4.5-11.0 thou/ul
RED BLOOD CELL
4.06
5.2-5.4 milliliter/ upper limit
HEMOGLOBIN
12.8
11.7-16.1 grams per deciliter
HEMATOCRIT
37.7
35.0-47.0 %
MEAN CORPUSCULAR VOLUME
93
85-99 factor level
MEAN CORPUSCULAR HEMOGLOBIN
31.7
MEAN CORPUSCULAR HEMOGLOBIN
CONCENTRATION
34.1
33-37
RED CELL DISTRIBUTION WIDTH
11.4-14.5
PLATELETS
242
130-400 thou/ul
SEGMENTED CELLS %
44
LYMPHOCYTES %
27
20.5-51.1
MONOCYTES %
6
1.7-9.3
EOSINOPHILS %
14
BAND CELLS %
8
Thou/ul= thousand upper limit
COMMENTS:
Occasional target cells
***End of Report***
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
24 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
LABORATORY DATA
SPECIMEN COLLECTED:
07-02-YYYY
SPECIMEN RECEIVED:
07-06-YYYY
TEST
RESULT
BACTERIOLOGY
SOURCE:
Sputum
SMEAR ONLY:
1+ gram positive cocci; rare white blood cells
CULTURE
1st PRELIMINARY
1+ gram negative rod
2nd PRELIMINARY
OTHER ROUTINE
CULTURES
FINAL REPORT
1+ Enterobacter cloacae
SENSITIVITIES
***End of Report***
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
25 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
EKG REPORT
Date of EKG:
06/30/YYYY
Time of EKG
1005
Rate
112
Sinus tachycardia. Myocardial changes of inferior
ischemia progressive from 01/09/YYYY. Occasional
premature ventricular contraction.
PR
12
QRSD
.08
QT
.32
QTC
-- Axis --
P
QRS
T
Reviewed and Approved:
Bella Kaplan, MD
ATP-B-S:02:1001261385:
Bella Kaplan, MD
(Signed: 07/01/YYYY 5:24:44 PM EST)
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
26 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
MEDICATION ADMINISTRATION RECORD
SPECIAL INSTRUCTIONS: Allergic to Aspirin
MEDICATION (dose and route)
DATE: 06/30
DATE: 07/01
DATE: 07/02
DATE: 07/03
TIME
INITIALS
TIME
INITIALS
TIME
INITIALS
TIME
INITIALS
Ampicillin 500 milligrams 4
times a day for 7 days
0800
----
0800
VS
0800
VS
0800
VS
1200
----
1200
VS
1200
VS
1200
----
1600
OR
1600
OR
1600
OR
1600
----
2000
OR
2000
OR
2000
OR
2000
----
Lanoxin 0.125 milligrams daily
0800
--
0800
VS
0800
VS
0800
VS
Lasix 20 milligram daily
0800
VS
0800
VS
0800
VS
0800
VS
Klotrix 1 tablet three times a
day
0800
----
0800
VS
0800
VS
0800
VS
1300
----
1300
VS
1300
VS
1300
VS
1800
OR
1800
OR
1800
OR
1800
OR
Erythromycin 500 milligrams
every 6 hours for 5 days
0600
----
----
----
0600
----
1200
----
----
----
1200
VS
1800
----
----
----
1800
OR
2400
----
----
----
2400
JD
Single Orders
PRN Medications
Aspirin 650 milligrams by
mouth every 4 hours as
needed for elevated
temperature
1530
OR
1215
VS
1930
OR
1805
OR
Tylenol 1 or 2 tablets by
mouth every 4-6 hours as
needed for fever
----
----
1530
OR
0800
VS
0820
VS
----
----
1950
OR
1600
OR
2345
OR
Dalmane 15 milligrams by
mouth every night at bedtime
as needed for sleep
----
----
2220
OR
2200
OR
2140
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
27 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
MEDICATION ADMINISTRATION RECORD
SPECIAL INSTRUCTIONS: Allergic to Aspirin
MEDICATION (dose and route)
DATE: 07/04
DATE: 07/05
DATE: 07/06
DATE: 07/07
TIME
INITIALS
TIME
INITIALS
TIME
INITIALS
TIME
INITIALS
Erythromycin 500 milligrams
every 6 hours for 5 days
0600
JD
0600
JD
0600
JD
0600
JD
1200
VS
1200
VS
1200
VS
1200
----
1800
OR
1800
OR
1800
OR
1800
----
2400
JD
2400
JD
2400
JD
2400
----
Lanoxin 0.125 milligrams daily
0800
VS
0800
VS
0800
VS
0800
VS
Lasix 20 milligram daily
0800
VS
0800
VS
0800
VS
0800
VS
Klotrix 1 tablet three times a
day
0800
VS
0800
VS
0800
VS
0800
VS
1300
VS
1300
VS
1300
VS
1300
----
1800
OR
1800
OR
1800
OR
1800
----
Dimetapp Extentabs
0800
VS
0800
VS
0800
VS
2000
OR
2000
OR
Afrin nasal spray 2 squeezes
each nostril every 12 hours
0800
----
0800
VS
2000
OR
2000
----
PRN Medications:
Tylenol 1 or 2 tablets every
4-6 hours as needed for pain
0830
JD
Dalmane 15 milligrams every
bedtime as needed for sleep
2200
OR
2230
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
28 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
NURSES’ NOTES
DATE
TIME
TREATMENTS & MEDICATIONS
TIME
NURSES’ NOTES
06/30/YYYY
1530
Wednesday Aspirin 650
milligrams for elevated
temperature.
1515
Resting in bed. Reminded patient to save
sputum for specimen and urine for
specimen.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 06/30/YYYY 03:31:03 PM EST)
1700
Regular diet
1700
Ate fair amount at dinner.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 06/30/YYYY 05:07:41 PM EST)
1930
101-104-20 126/70
Aspirin 650 milligrams for
elevated temperature. Urine
specimen sent to lab.
1900
Resting in bed.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 06/30/YYYY 07:31:41 PM EST)
2000
Evening care given.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 06/30/YYYY 08:06:03 PM EST)
2230
Resting quietly in bed.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 06/30/YYYY 10:33:44 PM EST)
07/01/YYYY
2400
Thursday
100.2-100-20 Aspirin 650
milligrams for elevated
temperature.
2400
Awake. Mild cough. Coughs occasionally.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 07/01/YYYY 12:03:16 AM EST)
0300
Sleeping.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 07/01/YYYY 03:08:22 AM EST)
0600
0615
101.2-96-20
Aspirin 650 milligrams for
elevated temperature.
0600
Awake for temperature, pulse, and
respirations. Slept well most of the
night. Medicine for elevated
temperature.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 07/01/YYYY 06:03:16 AM EST)
07/01/YYYY
0700
Appetite good for breakfast. Regular
diet. Non-productive cough noted.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 07/01/YYYY 07:05:33 AM EST)
1200
Lunch taken and tolerated well. Resting
quietly in bed.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/01/YYYY 12:16:00 PM EST)
LOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
29 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
NURSES’ NOTES
DATE
TIME
TREATMENTS & MEDICATIONS
TIME
NURSES’ NOTES
07/01/YYYY
1511
1530
Temperature 102.2
Tylenol 2 tablets for
elevated temperature.
1515
Resting in bed. Skin warm and moist.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/01/YYYY 03:36:00 PM EST)
1700
Regular diet.
1700
Ate moderate amount at dinner.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/01/YYYY 05:05:12 PM EST)
1900
100.3-100-20 120/60
1900
Resting in bed. Taking fluids well.
Coughing no sputum for specimen.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/01/YYYY 07:05:07 PM EST)
1950
Tylenol 2 tablets for
elevated temperature.
2000
Evening care given.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/01/YYYY 08:02:41 PM EST)
2230
Resting quietly in bed. Non-productive
cough noted.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/01/YYYY 10:32:01 PM EST)
07/02/YYYY
2400
Friday 99-100-24
2400
Sleeping on first rounds. Awakened for
Temperature, pulse, and respirations.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 07/02/YYYY 12:04:00 AM EST)
0600
Slept well through most of the night.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 07/02/YYYY 06:08:44 AM EST)
Tylenol 2 tablets given by
mouth.
0730
Awake. Vitals stable. Elevated
temperature 101.8. Encouraged to drink
fluids.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/02/YYYY 07:32:00 AM EST)
0800
Breakfast taken fair. Bathroom without
assistance. Self morning care.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/02/YYYY 08:04:22 AM EST)
0900
Dr. Black is in.
0900
Patient working on sputum. Face appears
slightly flushed and eyes very bright.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/02/YYYY 09:02:13 AM EST)
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
30 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
NURSES’ NOTES
DATE
TIME
TREATMENTS & MEDICATIONS
TIME
NURSES’ NOTES
07/02/YYYY
1200
Lunch taken fair.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/02/YYYY 12:02:17 PM EST)
1400
Resting. Still working on sputum
specimen.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/02/YYYY 02:03:00 PM EST)
07/02/YYYY
Temperature 101
1530
Resting quietly in bed. Temperature
elevated. States not coughing up as much
as previously.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/02/YYYY 03:32:50 PM EST)
1730
Diet taken poorly.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/02/YYYY 05:31:03 PM EST)
99.9-64-20 144/70
1930
Vitals taken. Complained of ears feeling
very “full.” Working at sputum
collection.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/02/YYYY 07:37:41 PM EST)
2030
Bedtime care given. No productive cough
noted.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/02/YYYY 08:32:28 PM EST)
2215
Out of bed to bathroom. Back to bed.
Comfortable.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/02/YYYY 10:16:03 PM EST)
07/03/YYYY
Saturday
2400
Awakened. Asked for Tylenol for
headache.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 07/03/YYYY 12:04:00 AM EST)
0600
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 07/03/YYYY 12:04:00 AM EST)
0730
To bathroom for self morning care and
returned to room.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South , RN
(Signed: 07/03/YYYY 07:37:11 AM EST)
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
31 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
NURSES’ NOTES
DATE
TIME
TREATMENTS & MEDICATIONS
TIME
NURSES’ NOTES
07/03/YYYY
1200
Out of bed in chair for lunch. Ate well.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/03/YYYY 12:06:00 PM EST)
1400
Resting quietly. No complaints offered.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/03/YYYY 02:02:20 PM EST)
1530
Resting in bed visiting with family.
Offers no complaint of discomfort at
present.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/03/YYYY 03:32:40 PM EST)
1700
Ate very poor regular diet.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/03/YYYY 05:02:40 PM EST)
1930
Temperature 101.2
1900
Sleeping soundly.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/03/YYYY 07:32:40 PM EST)
2020
Tylenol 2 tablets for
elevated temperature.
2030
Bedtime care given. Temperature elevated
a little.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/03/YYYY 08:31:34 PM EST)
2200
Appears to be sleeping.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/03/YYYY 10:03:00 PM EST
07/04/YYYY
2400
Sunday
97.7–76-24
2400
Sleeping on first rounds. Awakened for
temperature, pulse, and respirations.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs RN
(Signed: 07/04/YYYY 12:01:00 AM EST)
0300
Sleeping.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs RN
(Signed: 07/04/YYYY 03:02:20 AM EST)
0600
Slept well most of the night. Still
sounds congested.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs RN
(Signed: 07/04/YYYY 06:05:46 AM EST)
32 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
NURSES’ NOTES
DATE
TIME
TREATMENTS & MEDICATIONS
TIME
NURSES’ NOTES
07/04/YYYY
0800
Dr. Black is in.
0800
Breakfast taken well. Self morning care
taken in bathroom.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs RN
(Signed: 07/04/YYYY 08:05:46 AM EST)
1000
Out of bed sitting in chair, watching
television. No cough noted.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/04/YYYY 10:07:13 AM EST)
1200
Lunch taken well.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/04/YYYY 12:04:00 PM EST
1400
Resting quietly.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/04/YYYY 02:03:45 PM EST
07/04/YYYY
Temperature 99.6
1530
Awake resting quietly in bed, complains
of being hungry and requested coffee and
cookies—given to her.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/04/YYYY 03:34:20 PM EST
1700
Ate very good dinner. Resting quietly.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/04/YYYY 05:33:12 PM EST
2030
Temperature 99.8
Tylenol 2 tablets for
elevated temperature.
2000
Complains of being cold. Temperature
elevated. Given more blankets.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/04/YYYY 08:36:50 PM EST)
2200
Appears to be sleeping soundly.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/04/YYYY 10:03:34 PM EST)
07/05/YYYY
2400
Monday
96.9-88-16
2400
Sleeping on first rounds. Awakened for
temperature, pulse, and respirations.
Skin warm and moist. Pajamas changed and
made comfortable.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 07/05/YYYY 12:05:00 AM EST
0300
Sleeping soundly.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 07/05/YYYY 03:03:10 AM EST)
33 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
NURSES’ NOTES
DATE
TIME
TREATMENTS & MEDICATIONS
TIME
NURSES’ NOTES
07/05/YYYY
Monday
0600
Slept well most of the night. Still
sounds congested.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 07/05/YYYY 06:02:49 AM EST)
0730
Morning vitals taken.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/05/YYYY 07:37:13 AM EST)
0800
Breakfast taken fairly well.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/05/YYYY 08:02:23 AM EST)
0830
Self morning care in the bathroom.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/05/YYYY 08:32:00 AM EST)
1000-
1100
Patient out in chair sitting for most of
the morning.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/05/YYYY 11:02:00 AM EST)
1200
Dr. Black is in. Patient takes lunch
fairly well.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/05/YYYY 12:04:20 PM EST)
1300-
1400
Patient resting quietly in bed and
offered no complaints. Had a fairly good
day.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/05/YYYY 02:01:46 PM EST)
1530
Resting quietly in bed.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/05/YYYY 03:32:17 PM EST)
1700
Ate well at dinner.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/05/YYYY 05:03:10 PM EST
1900
Up and about in room.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/05/YYYY 07:02:00 PM EST)
34 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
NURSES’ NOTES
DATE
TIME
TREATMENTS & MEDICATIONS
TIME
NURSES’ NOTES
07/05/YYYY
Monday
2000
Evening care given. Voiding quantity
sufficient in bathroom.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/05/YYYY 08:02:00 PM EST)
2230
Resting in bed.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/05/YYYY 10:32:50 PM EST)
07/06/YYYY
Tuesday
2400
Asleep on rounds. Respirations sound a
little full. Side rails up. No
complaints.
Reviewed and Approved: J. Dodds, RN
ATP-B-S:02:1001261385: J. Dodds, RN
(Signed: 07/06/YYYY 12:02:49 AM EST)
0300
Continues to sleep.
Reviewed and Approved: J. Dodds, RN
ATP-B-S:02:1001261385: J. Dodds, RN
(Signed: 07/06/YYYY 03:04:09 AM EST)
0600
Remains sleeping this morning. No cough
noted.
Reviewed and Approved: J. Dodds, RN
ATP-B-S:02:1001261385: J. Dodds, RN
(Signed: 07/06/YYYY 06:02:19 AM EST)
07/06/YYYY
0800
98.9-92-20 132/78
Regular diet
0800
Self morning care in bathroom. Ate well
for breakfast. No complaints. Occasional
harsh cough noted.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/06/YYYY 08:12:55 AM EST)
1200
Regular diet
Temperature 97.2
1200
Ate well for lunch. Ambulated as
desired.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/06/YYYY 12:05:45 PM EST)
1430
Dr. Black in.
1430
Comfortable day.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/06/YYYY 02:32:55 PM EST)
07/06/YYYY
1530
Resting in bed.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/06/YYYY 03:32:17 PM EST)
1700
Regular diet.
1700
Ate well at dinner.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/06/YYYY 05:02:17 PM EST)
35 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
NURSES’ NOTES
DATE
TIME
TREATMENTS & MEDICATIONS
TIME
NURSES’ NOTES
07/06/YYYY
Tuesday
1900
Up and about in room.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/06/YYYY 07:02:17 PM EST)
1930
99.3-80-20 100/64
2000
Evening care given. Took bedtime snack
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/06/YYYY 08:01:34 PM EST)
2230
Resting quietly in bed.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 07/06/YYYY 10:34:06 PM EST)
07/07/YYYY
11-7
Wednesday
2400
Asleep on rounds. No complaints.
Respirations sounding more clear. Side
rails up.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385:J. Dobbs, RN
(Signed: 07/07/YYYY 12:03:07 AM EST)
0300
Continues to sleep.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385:J. Dobbs, RN
(Signed: 07/07/YYYY 03:01:17 AM EST)
0600
Slept fairly well throughout the night.
Respirations clear. No complaints.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385:J. Dobbs, RN
(Signed: 07/07/YYYY 06:05:38 AM EST)
07/07/YYYY
0730
Awake. Vitals stable. Anxious for
discharge.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385:J. Dobbs, RN
(Signed: 07/07/YYYY 07:03:27 AM EST)
0800
Took breakfast well – appetite good.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/07/YYYY 08:04:53 AM EST)
Dr. Black in. Discharged
to home.
0900
Morning care done. No complaints.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/07/YYYY 09:02:12 AM EST)
1000
Discharged to home. Instructions given
to patient.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/07/YYYY 10:02:23 AM EST)
36 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
NURSING DISCHARGE
STATUS SUMMARY
1.
AFEBRILE:
X
Yes
No
140/80 98 – 80 - 20
2.
WOUND:
Clean/Dry
Reddened
Infected
NA X
3.
PAIN FREE:
Yes
X
No
If “No,” describe: Requires Tylenol as needed.
4.
POST-HOSPITAL INSTRUCTION SHEET GIVEN TO PATIENT/FAMILY:
Yes
X
No
If NO, complete lines 5-8 below.
5.
DIET:
X
Regular
Other (Describe):
6.
ACTIVITY:
X
Normal
Light
Limited
Bed rest
7.
MEDICATIONS:
None
8.
INSTRUCTIONS GIVEN TO PATIENT/FAMILY:
As ordered by Dr. Black
9.
PATIENT/FAMILY verbalize understanding of instructions:
X
Yes
No
10.
DISCHARGED at
1000
Via:
Wheelchair
X
Stretcher
Ambulance Co.
Ambulatory
Accompanied by:
Vera South, RN
to
Front lobby
COMMENTS:
To front lobby. Ambulated with assistant to home with
family.
Cast on left arm.
DATE:
07/07/YYYY
SIGNATURE:
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 07/07/YYYY 10:02:15 AM EST
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
37 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green.
PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
PATIENT PROPERTY RECORD
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.
Reviewed and Approved: Sally Pire
ATP-B-S:02:1001261385: Sally Pire
(Signed: 06/30/YYYY 01:35:05 PM EST)
06/30/YYYY
Signature of Patient
Date
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 06/30/YYYY 01:37:23 PM EST
06/30/YYYY
Signature of Witness
Date
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.
Reviewed and Approved: Sally Pire
ATP-B-S:02:1001261385: Sally Pire
(Signed: 06/30/YYYY EST) 01:38:00 PM
06/30/YYYY
Signature of Patient
Date
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 06/30/YYYY EST) 01:39:18 PM
06/30/YYYY
Signature of Witness
Date
I have deposited valuables in the facility safe. The envelope number is .
Signature of Patient
Date
Signature of Person Accepting Property
Date
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.
Signature of Patient
Date
Signature of Witness
Date
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
Students also viewed