Microsoft Word – IPCase001.doc Global Care Medical

Microsoft Word – IPCase001.doc Global Care Medical Center 100 Main St, Alfred NY 14802 (607) 555-1234 Hospital No. 999 LONG, BETH F W M IPCase001 4983 REED STREET ALMOND, NY 14804 12/17/YYYY 30 Short Clerk ! 04/26/YYYY 1350 04/30/YYYY 1150 04 DAYS (607)555-3319 ” # LONG, BERNIE 4983 REED STREET ALMOND, NY 14804 LONG, BERNIE 4983 REED STREET ALMOND, NY 14804 ” # ! (607)555-3319 John Black, MD John Black, MD Husband (607)555-3319 Husband 369 Fever of undetermined origin $ ! % & ! & ! Acute Pyelonephritis Dehydration & $ : ‘ Follow-Up: office in one week & : N o n e Bed rest Regular Call for appointment Office appointment on Other: To be seen for a follow up in Light Low Cholesterol Usual Low Salt ADA Unlimited Other: Calorie ‘ Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 4/30/YYYY 2:20:44 PM EST) LONG, BETH IPCase001 Dr. BLACK Admission:04/26/YYYY DOB: 12/17/YYYY ROOM: 369 I, Beth Long 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: Beth Long ATP-B-S:02:1001261385: Beth Long (Signed: 4/26/YYYY 2:12:05 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: 4/26/YYYY 2:12:05 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: Beth Long ATP-B-S:02:1001261385: Beth Long (Signed: 4/26/YYYY 2:14:17 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: 4/26/YYYY 2:16:24 PM EST WITNESS: Global Care Medical Center Staff Member GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 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. Have you been provided with a copy of the information called “Patient Rights Regarding Health Care Decision?” Have you prepared a “Living Will?” If yes, please provide the Hospital with a copy for your medical record. YES NO X X PATIENT’S INITIALS 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. Verify the above questions where and actions taken where required. If the “Patient Rights” information was provided to someone other than the patient, state reason: Name of Individual Receiving Information Relationship to Patient If information was provided in a language other than English, specify language and method. Verify patient was advised on how to obtain additional information on Advance Directives. 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: Beth Long ATP-B-S:02:1001261385: Beth Long (Signed: 4/26/YYYY 2:35:05 PM EST) Signature of Patient Date Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 4/26/YYYY 2:35:47 PM EST Signature of Hospital Representative Date GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ADMISSION DATE: 04/26/YYYY ADMISSION DIAGNOSIS: Fever DISCHARGE DIAGNOSIS: Acute DISCHARGE DATE: 04/30/YYYY of undetermined origin. pyelonephritis. SUMMARY: This 30 year old white female had high fever off and on for several days prior to admission without any localizing signs or symptoms. Preliminary studies done as an outpatient were unremarkable except to indicate an infection some place. She was ultimately seen in the office, temperature was 103 to 104. She was becoming dehydrated, washed out, weak, tired, and she was admitted for further workup and evaluation. Workup included a chest x-ray, which was normal. Intravenous pyelogram was also normal. Blood culture report was normal. Urine culture grew out Escherichia coli greater than 100,000 colonies. Throat culture was normal. One blood culture did finally grow out an alpha strep viridans. I talked to Dr. Burke about this and we decided on the basis of her clinical condition and the fact that this did not grow on all bottles it was more likely a contaminate. Urine showed a specific gravity of 1.010, albumin 1+, sugar and acetone were negative, white blood cells 6 to 8, and red blood cells 1 to 2. White count 13,100, Hemoglobin 12, hematocrit 35.1, segmental cells 81, lymphocytes 11, monocytes 5, eosinophils 1, bands 2. Mononucleosis test was negative. Alkaline phosphatase 127, blood sugar 125, sodium 142, potassium 4.7, carbon dioxide 30, chloride 104, cholesterol 119, Serum glutamic oxaloacetic transaminase 41, lactate dehydrogenase 151, creatinine 0.9, calcium 9.8, phosphorus 3.3, bilirubin 0.6, total protein 6.8, albumin 4.0, uric acid 6.5. Electrocardiogram was reported as normal. She was started on intravenous fluids, intravenous Keflex, her temperature remained elevated for approximately 48 hours and now has been normal for the last 48 to 72 hours. She feels better, hydration is better, eating better, no urinary symptoms. She’s being discharged at this time on Keflex 500 four times per day, increased fluid intake. To be seen in follow up in the office in 1 week. DD: 04/30/YYYY Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 5/1/YYYY 2:24:44 PM EST) DT: 05/01/YYYY Physician Authentication GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ADMISSION DIAGNOSIS: Fever undetermined etiology, pyelonephritis, dehydration, and possible urinary tract infection. CHIEF COMPLAINT: Chills and fever, and just feels lousy for the last 5 days. HISTORY OF PRESENT ILLNESS: The patient began to run a temperature on Sunday, had no other complaints whatsoever. She has not felt like eating for the past 5 days and only taking in fluids and Aspirin. She was seen in the office on 4/24 with 98 degree temperature but she had just taken Aspirin. At that time physical exam was negative but she had an 18,300 white count. The white count was repeated the next day and found to be 13,400 with temperature elevated at 102-103 unless she was taking Aspirin. She was seen in the office again today, continues to feel lousy and now she has some pain in the left upper flank area posteriorly, she is being admitted to the hospital for a workup with a temperature of 103. FAMILY HISTORY: Negative for cancer, tuberculosis, diabetes, she has a brother with mild epilepsy. PAST HISTORY: She has only been admitted for delivery of her 2 children, otherwise she has always been in excellent health without any problems. She smokes 15-20 cigarettes a day and has done so for the last 15 years. She doesn’t drink. She uses no other drugs. SOCIAL HISTORY: She lives at home with her husband and 2 children. There are no apparent problems. REVIEW OF SYSTEMS: Normal except for the history of the present problem. GENERAL: Shows a cooperative young lady. She shows no pain. She is 30 years old. WEIGHT: 113 lb. TEMPERATURE: 103 oral PULSE: 102 RESPIRATIONS: 18 SKIN: Pink, warm, dry, no evidence of rash or jaundice. HEENT: Head symmetrical. No masses or abnormalities. Eyes react to light and accommodation. Extraocular movements are normal. Sclera is clear. Ears, tympanic membranes are not injected. Mouth and throat are negative. NECK: Supple. No lymph notes felt. No thyromegaly. CHEST: Clear to percussion and auscultation. HEART: Normal sinus rhythm. Not enlarged. ABDOMEN: Soft. She is tender under the left costal margin with no enlargement of any organs. She has pain to percussion in left upper flank area. PELVIC & RECTAL: Deferred. EXTREMITIES: Normal. Peripheral pulses DD: 04/26/YYYY DT: 04/26/YYYY are normal. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 4/26/YYYY 2:24:44 PM EST) Physician Authentication GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 Date Time Physician’s signature required for each order. (Please skip one line between dates.) 04/27/YYYY 1450 Chief complaint: left flank pain; fever. Diagnosis: pyelonephritis; dehydration; rule out renal calculus. Plan of Treatment: Admit. Hydration with intravenous Ancef. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 4/27/YYYY 2:50:55 PM EST) 04/28/YYYY 1110 Alpha strep in blood culture. Not viridans, clinically. Improving. Has genitourinary infection; urinary tract infection. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 4/28/YYYY 11:14:07 AM EST) 04/29/YYYY 1140 Patient feels better; still complains of left flank and back pain. SUBJECTIVE: Afebrile vital signs. OBJECTIVE: HEAD/EYES/EARS/NOSE/THROAT: Tympanic membrane of left ear somewhat dull yellowish. Throat: slight erythema. Heart: regular rate and rhythm, without murmur. Back: positive left costovertebral angle tenderness. Abdomen: mild left upper quadrant. ASSESSMENT/PLAN: 1) Probable left pyelonephritis. Rule out stone. 2) Positive streptococcal bacteremia. Possibly secondary to pyelonephritis. Possible other source? Abscess – doubt. Intravenous pyelogram is okay. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 4/29/YYYY 11:40:32 AM EST) GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 Date Time Physician’s signature required for each order. (Please skip one line between dates.) 04/26/YYYY 1400 Complete blood count and mononucleosis test. Urinalysis. Urine for culture and sensitivity. Throat culture. Blood culture every one-half hour times two until next temperature increases to 101 degrees. Chest x-ray done as outpatient. Electrocardiogram. SCG #2. Electrolytes. Full liquids as tolerated. Intravenous fluids, 50-100 cubic centimeters per hour. Tylenol 2 tabs every 4 to 6 hours as needed for elevated temperature. Ancef 500 milligrams intravenous every 6 hours (after cultures are obtained. History and physical examination report dictated. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 4/26/YYYY 2:04:00 PM EST) 04/27/YYYY 1110 Please schedule for intravenous pyelogram, Monday morning. Soft diet as tolerated. Strain urine. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 4/27/YYYY 11:24:52 AM EST) 04/29/YYYY 1515 Discontinue intravenous fluids in morning. Discontinue Ancef in morning. Start on Keflex, 500 milligrams four times per day in morning on April 30. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 4/29/YYYY 3:24:00 PM EST) 04/30/YYYY 1315 Discharge to home. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 4/30/YYYY 1:16:32 PM EST) GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 SPECIMEN COLLECTED: 04/26/YYYY LONG, BETH IPCase001 DR. BLACK URINALYSIS DIPSTICK ONLY COLOR SPECIFIC GRAVITY GLUCOSE BILIRUBIN KETONE BLOOD PH PROTEIN UROBILINOGEN NITRITES LEUKOCYTE WHITE BLOOD CELLS RED BLOOD CELLS BACTERIA URINE PREGNANCY TEST YELLOW 1.010 NEGATIVE NEGATIVE TRACE TRACE 6.5 NORMAL NORMAL NEGATIVE NEGATIVE 6-8/hpf **H** 1-2/hpf MANY **H** Negative SPECIMEN RECEIVED: 04/26/YYYY ≤ 1.030 ≤ 125 mg/dl ≤ 0.8 mg/dl ≤ 10 mg/dl 0.06 mg/dl hgb 5-8.0 ≤ 30 mg/dl ≤ -1 mg/dl NEG ≤ 15 WBC/hpf ≤ 5/hpf ≤ 5/hpf 1+(≤ 20/hpf) ≤ = less than or equal to = greater than or equal to mg/dl = milligrams per deciliter hgb = hemoglobin /hpf = per high power field ***End of Report*** GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 SPECIMEN COLLECTED: 04/26/YYYY 1450 SPECIMEN RECEIVED: 04/29/YYYY 1814 LONG, BETH IPCase001 Dr. BLACK BACTERIOLOGY SOURCE: SMEAR ONLY: CULTURE 1stPRELIMINARY 2nd PRELIMINARY FINAL REPORT SENSITIVITIES R = Resistant S = Sensitive OTHER ROUTINE CULTURES Blood Cultures Nobacteriaseenat24hours. Strep viridans 1. S AMIKACIN AMPICILLIN CARBENICILLIN CEFAMANDOLE CEFOXITIN CEPHALOTHIN CLINDAMYCIN ERYTHROMYCIN GENTAMICIN KANAMYCIN METHICILLIN NALIDIXIC ACID NITROFURANTOIN PENICILLIN G POLYMYXIN B SULFISOXAZOLE TETRACYCLINE TRIMETHOPRIM VANCOMYCIN 1. R 1.S CHLORAMPHENICOL 1. R 1. S 1. S 1. S 1. S 1. S 1. S GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK SPECIMEN COLLECTED: BACTERIOLOGY SOURCE: SMEAR ONLY: CULTURE 1st PRELIMINARY 2nd PRELIMINARY FINAL REPORT SPECIMEN RECEIVED: 04/29/YYYY 1814 Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 04/26/YYYY 1504 OTHER ROUTINE CULTURES Blood culture No bacteria seen at 24 hours No growth seen on 24 hour subculture ***End of Report*** GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 04/26/YYYY1450 04/26/YYYY1746 127 125 142 4.7 30 104 119 41 151 0.9 9.8 3.3 0.6 6.8 4.0 6.5 ACID PHOSPHATASE ALKALINE PHOSPHATASE AMYLASE LIPASE GLUCOSE FASTING GLUCOSE BUN SODIUM POTASSIUM CARBON DIOXIDE CHLORIDE CHOLESTEROL SERUM GLUTAMATE PYRUVATE TRANSAMINASE SERUMGLUTAMICOXALOCETIC TRANSAMINASE CREATININE KINASE LACTATE DEHYDROGENASE CREATININE CALCIUM PHOSPHORUS BILIRUBIN-DIRECT BILIRUBIN-TOTAL TOTAL PROTEIN ALBUMIN URIC ACID TRIGLYCERIDE 0.0-0.8 U/I 50-136 U/I 23-85 U/I 4-24 U/I 70-110 mg/dl Time collected 7-22 mg/dl 136-147 mEq/1 3.7-5.1 mEq/l 24-32 mEq/l 98-108 mEq/l 120-280 mg/dl 3-36 U/I M-27-47U/I M-35-232 U/I 100-190 U/I M-0.8-1.3 mg/dl 8.7-10.2 mg/dl 2.5-4.9 mg/dl 0.0-0.4 mg/dl Less than 1.5 mg/dl 6.4-8.2 g/dl 3.4-5.0 g/dl M-3.8-7.1 mg/dl 30-200 mg/dl F-22-37U/I F-21-215 U/I F-0.6-1.0 mg/dl F-2.6-5.6 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 LONG, BETH IPCase001 Dr. BLACK BACTERIOLOGY SOURCE: SMEAR ONLY: CULTURE 1stPRELIMINARY 2nd PRELIMINARY FINAL REPORT SENSITIVITIES R = Resistant S = Sensitive › = greater than Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 04/26/YYYY 1505 04/28/YYYY 1957 OTHER ROUTINE CULTURES Urine 1+ white blood cells, 4+ gram negative rods 1.CC=>100,000Escherichiacoli 1. CC = >100,000 Escherichia coli 1. S 1. R 1. R 1. S 1. S 1. S 1. R 1. S AMIKACIN AMPICILLIN CARBENICILLIN CEFAMANDOLE CEFOXITIN CEPHALOTHIN CHLORAMPHENICOL CLINDAMYCIN ERYTHROMYCIN GENTAMICIN KANAMYCIN METHICILLIN NALIDIXIC ACID 1. S 1. R 1. R 1. S NITROFURANTOIN PENICILLIN G POLYMYXIN B SULFISOXAZOLE TETRACYCLINE TRIMETHOPRIM VANCOMYCIN GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK WHITE BLOOD CELL RED BLOOD CELL HEMOGLOBIN HEMATOCRIT MEAN CORPUSCULAR VOLUME MEAN CORPUSCULAR HEMOGLOBIN MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION RED CELL DISTRIBUTION WIDTH PLATELETS SEGMENTED CELLS % LYMPHOCYTES % MONOCYTES % EOSINOPHILS % BAND CELLS % Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 04/26/YYYY 1450 04/26/YYYY 1746 4.5-11.0 thou/ul 5.2-5.4 milliliter/ upper limit 11.7-16.1 grams per deciliter 35.0-47.0 % 85-99 factor level 33-37 11.4-14.5 130-400 thou/ul 20.5-51.1 1.7-9.3 Thou/ul= thousand upper limit 13.1 3.99 12.0 35.1 87.9 30.2 34.3 355 81 11 5 1 2 ***End of Report*** GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 Date of X-ray: 04/29/YYYY REASON: Fever of unknown TECHNICAL DATA: No known intravenous – no reaction origin. allergies. 100 milliliter infusion through noted. INTRAVENOUS PYELOGRAM: A plain film taken prior to the intravenous pyelogram shows no shadows of urological significance. Following the intravenous injection of contrast material, serial films including anterior-posterior and oblique views show that both kidneys are normal in size and configuration. The right kidney is slightly ptotic and there is some buckling of the right proximal ureter. However, I do not think that this finding is clinically significant. The visualized course of the distal ureters are both normal. The bladder is well visualized on a delayed film and is within normal limits. There is a small amount of urinary residual on the post voiding film. CONCLUSION: Essentially normal intravenous pyelogram. DD: 04/29/YYYY Reviewed and Approved: Randall Cunningham MD ATP-B-S:02:1001261385: Randall Cunningham MD (Signed:4/29/YYYY 2:24:44 PM EST) DT: 04/29/YYYY GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 Date of Electrocardiogram: 04/26/YYYY Time of Electrocardiogram: 1600 90 .12 .68 .32 — Axis — P QRS T Rate PR QRSD QT QTC Sinus rhythm normal. Reviewed and Approved: Dr. Steven J. Chambers, M.D. ATP-B-S:02:1001261385: Dr. Steven J. Chambers, M.D. (Signed:4/29/YYYY 2:24:44 PM EST) GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 DAY IN HOSPITAL DATE PULSE () 140 130 120 110 100 90 80 70 60 50 40 30 20 RESPIRATION BLOOD PRESSURE WEIGHT 5’8″ DIET APPETITE BATH INT AKE/OUTPUT 1234 04/26/YYYY 04/27/YYYY 04/28/YYYY 04/29/YYYY 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 X X XX TEMP (X) 106 105 104 103 102 101 100 98.6 X XX XXXXX 98 X 97 96 95 X XX 99 XX X X 20 20 16 20 20 18 16 20 20 20 20 18 16 16 20 18 16 20 18 18 0800 1600 110/65 0800 110/70 1600 112/68 0800 100/70 1600 110/70 0800 108/68 1600 1200 102/60 2000 90/60 1200 90/65 2000 110/69 1200 110/70 2000 105/68 1200 95/72 2000 141# Full liquid Full liquid Soft Soft ORALFLUIDS IV FLUIDS BLOOD 8-HOUR TOT AL 24-HOUR TOT AL URINE STOOL EMESIS NASOGASTRIC 8-HOURTOTAL 24-HOUR TOT AL 50% 50% 100% 100% 30% 90% Self Self 7-3 3-11 11-7 7-3 3-11 11-7 7-3 600 100 650 1350 200 600 500 600 600 850 550 650 75% 100% 100% 100% 80% Self Self 3-11 11-7 7-3 3-11 11-7 1170 100 850 440 650 1050 700 600 1100 700 1250 2200 750 1250 1820 1150 1550 1040 1800 4200 4220 2590 800 600 1100 750 650 700 1175 700 1000 900 2 loose 800 600 1100 750 650 700 1175 700 1000 900 1400 2500 2575 1900 GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 OUTPUT INTAKE LONG, BETH IPCase001 Dr. BLACK 90 Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 DAY IN HOSPITAL DATE PULSE () 140 130 120 110 100 80 70 60 50 40 30 20 RESPIRATION BLOOD PRESSURE WEIGHT 5’8″ DIET APPETITE BATH INT AKE/OUTPUT TEMP (X) 106 105 104 103 102 101 100 99 98.6 98 97 96 95 5 04/30/YYYY 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 X 20 0800 1200 102/60 2000 141# Full liquid 50% Self 7-3 1600 ORAL FLUIDS IV FLUIDS BLOOD 8 HOUR TOTAL 24 HOUR TOTAL URINE STOOL EMESIS N-G 8 HOUR TOTAL 24 HOUR TOTAL GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 OUTPUT INTAKE LONG, BETH IPCase001 Dr. BLACK SPECIAL INSTRUCTIONS: Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 MEDICATION (dose and route) DA TE: 04/26 DATE: 04/27 DA TE: 04/28 DA TE: 04/29 TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALS Ancef 500 mg IV q6° 0600 — 0600 — 0600 JD 0600 JD (started before 1200 — 1200 VS 1200 JD 1200 HF cultures obtained) 1800 OR 1800 HF 1800 OR 1800 OR 2400 JD 2400 OR 2400 OR 2400 OR mg = milligrams IV = intravenous PRN Medications: Tylenol 2 tabs by mouth 1930 OR 0435 JD 0520 JD 0600 JD daily 4 to 6 hours as 1100 VS 1230 HF needed for increased 1830 HF temperature PRN = as needed INITIALS SIGNATURE AND TITLE INITIALS VT Vera South, RN GPW OR Ora Richards, RN PS JD Jane Dobbs, RN HF H. Figgs RN SIGNATURE AND TITLE G. P. Well, RN P. Small, RN INITIALS SIGNATURE AND TITLE GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK SPECIAL INSTRUCTIONS: Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 MEDICATION (dose and route) DATE: 04/30 DATE: DATE: DATE: TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALS Keflex 500 milligram 0800 HF four times a day INITIALS SIGNATURE AND TITLE VT Vera South, RN OR Ora Richards, RN JD Jane Dobbs, RN HF H. Figgs RN INITIALS SIGNATURE AND TITLE GPW G. P. Well, RN PS P. Small, RN INITIALS SIGNATURE AND TITLE GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK 4/27 1400 1000 cubic centimeter none #209 Cathalin left arm 100 cubic centimeter per hour JD 4/28 0100 1000 cubic centimeter none added 100 cubic centimeter per hour HF 4/28 1300 1000 cubic centimeter none same 100 cubic centimeter per hour JD 4/29 2400 1000 cubic centimeter —- —- 100 cubic centimeter per hour OR Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 4/29 Intravenous sore Discontinued JD 1330 site 4/29 1340 1000 cubic centimeter none #209 Cathalin left antecubital 100 cubic centimeter per hour 4/30 2400 1000 cubic centimeter 100 cubic centimeter per hour 4/30 0900 1000 cubic centimeter 100 cubic centimeter per hour 4/30 2200 1000 cubic centimeter 100 cubic centimeter per hour 4/31 0750 Intravenous discontinued JD OR HF VT HF 150 cubic centimeters remaining in bag. No signs of infiltration or redness at site. Nurse’s Signature Vera South RN (VT) H. Figgs RN (HF) Needle removed intact. Ora Richards RN (OR) Jane Dodds RN (JD) GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 Time Solution & Amount Medication Added Injection Site & Mode Rate IV & CVP Redress Site Changed q 48 hours Nurse’s Initials Remarks LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 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: Beth Long ATP-B-S:02:1001261385: Beth Long (Signed: 4/26/YYYY 2:24:44 PM EST Signature of Patient Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 4/26/YYYY 1:44:00 PM EST Signature of Witness 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: Beth Long ATP-B-S:02:1001261385: Beth Long (Signed: 4/26/YYYY 1:46:44 PM EST Signature of Patient Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 4/26/YYYY 1:48:28 PM EST Signature of Witness I have deposited valuables in the facility safe. The envelope number is . Signature of Patient Signature of Person Accepting Property 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 Signature of Witness GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 DATE TIME TREATMENTS & MEDICATIONS TIME NURSE’S NOTES 4/26/YYYY 1400 A 30 year old female admitted to room 369 services of Dr. Black. Oriented to room and call system. Urine culture sent to lab. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/26/YYYY 2:00:10 PM EST) 4/26/YYYY 1430 Resting in bed. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/26/YYYY 2:30:23 PM EST) 1530 Resting comfortably in bed. Intravenous infusing well. Temperature decreased to 99°. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/26/YYYY 3:31:00 PM EST) 1930 Tylenol, 2 tablets by mouth for increased temperature. 2000 Vitals taken. Temperature increased to 103. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/26/YYYY 8:04:05 PM EST) 2045 Refused backrub. States she gets chilled and then too warm. Face is flushed at present. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/26/YYYY 8:45:44 PM EST) 2215 Appears asleep. Respirations even. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/26/YYYY 10:15:17 PM EST) 2330 Temperature 100.1. Pulse 80. Respirations 16. 2330 Sleeping. Awakened for vital signs. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 11:30:34 PM EST) 4/27/YYYY Saturday 0200 Sleeping. Respirations even. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 2:24:20 AM EST) 0405 102.7 – 100 – 20 0415 Awake. Vital signs taken. Skin warm to touch. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 4:15:04 AM EST) 0430 Tylenol tabs 2 by mouth for increased temperature. Intravenous infusing well. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 4:31:44 AM EST) 0600 Resting quietly. Skin cooler. 0600 Temperature – 100.2 Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 6:00:02 AM EST) GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 DATE TIME TREATMENTS & MEDICATIONS TIME NURSE’S NOTES 0730 Temperature decreased. Vital signs stable. States feels better. Intravenous infusing well. Voiding without difficulty. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 7:30:16 AM EST) 4/27/YYYY 0800 Ate all of breakfast. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/27/YYYY 8:00:41 AM EST) 0830 Patient took shower with bag over intravenous site. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/27/YYYY 8:30:28 AM EST) 1000 Moves well. Walking to day room to smoke. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/27/YYYY 10:01:03 AM EST) 1130 Temperature 104 1130 Complains of chills. Temperature increased. Lying in bed. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/27/YYYY 11:30:44 AM EST) 1700 Up as desired to smoke. Supper taken fair. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/27/YYYY 5:00:17 PM EST) 1800 Complains of feeling ‘shaky’ and felt fever coming on. Temperature = 102. Charge notified and patient given Tylenol 2 tabs. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/27/YYYY 6:02:41 PM EST) 2000 Patient complains of ‘sweats.’ Patient’s skin moist & warm. Temperature = 100.3. Encouraged to drink fluids. Voiding well. No sediment or stones strained from urine. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/27/YYYY 8:00:10 PM EST) 2200 Awake. No stones strained from urine. Temperature at 2200 – 98.4. Skin less diaphoretic. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/27/YYYY 10:00:51 PM EST) 4/27/YYYY 2330 Temperature 98.1. Pulse 72. Respirations 20. 2330 Awake. Reading. No complaints offered. Intravenous infusing well. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 11:30:16 AM EST) GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 DATE TIME TREATMENTS & MEDICATIONS TIME NURSE’S NOTES 4/28/YYYY Sunday 0200 Sleeping at present. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/28/YYYY 2:00:35 AM EST) 0500 Awakened for vital signs. Temperature increased. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/28/YYYY 5:02:00 AM EST) 0520 Tylenol tabs 2 by mouth for increased temperature. Medicated. Intravenous infusing well. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/28/YYYY 5:20:18 AM EST) 0630 Sleeping at present. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/28/YYYY 6:30:16 AM EST) 0730 Awake for vitals. Ambulatory in hall. Ate 90% of breakfast to bathroom for shower. Sitting out of bed in a chair. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/28/YYYY 7:30:00 AM EST) 1200 Ate 75% of lunch. Ambulatory. To day room to smoke. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/28/YYYY 12:03:00 PM EST) 1400 All urine strained. No calculi noted. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/28/YYYY 2:00:40 PM EST) 1530 In day room visiting. Vitals taken. Intravenous infusing well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/28/YYYY 3:30:04 PM EST) 4/28/YYYY 1830 Ambulatory as desired. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/28/YYYY 6:30:35 PM EST) Sunday 1930 Vitals taken. Temperature decreased. Preparation effective. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/28/YYYY 7:30:06 PM EST) No calculi noted 2030 Refused backrub. Clear juice taken. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/28/YYYY 8:30:17 PM EST) Large amount white sediment. 2200 Resting in bed. Awake. Television on. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/28/YYYY 10:00:44 PM EST) GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 DATE TIME TREATMENTS &

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