Edward C Newman Record
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Sundance HealthCare Systems Painted Valley, USA NAME
Newman, Edward C.
X-RAY NO.
47932
DOCTOR
Dr. W. J. Wainwright
DATE
8/14/xx
REGION EXAMINED
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502
CHEST X-RAY
Indications: SOB CHEST:
There is mild to moderate pulmonary vascular congestion. There is mild bilateral interstitial edema. The findings are less prominent than on 1-1-xx. No focal consolidation is seen in the lungs.
WCR/smb
William C. Roentgen RADIOLOGIST'S SIGNATURE
© 2003. American Health Information Management Association. All rights reserved.
M.D.
Sundance Medical Center Painted Valley, USA
Patient Name: Newman, Edward C. Physician: Dr. William J. Wainwright Room No. Coronary care unit
# 012502 Instructions: Please follow the instructions given below. This is an important part of your continued recovery. If, after reading the instructions, you have any questions please ask your physician/nurse for clarification. 1500 calorie ADA, no added salt diet.
Diet:
Medications:
Diazepam 20 mg p.o. q.h.s., albuterol and Atrovent nebulizers q.d. and p.r.n., Lasix 160
mg p.o. b.i.d.; Theo-Dur 200 mg q.a.m., 300 mg q.h.s.; Imdur 30 mg (1/2 tab) q.h.s., Pilocarpine 4% 1 drop O.D. q.i.d., nitroglycerin 0.4 mg sublingual p.r.n. chest pain, oxygen 2 to 4 liters per minute per nasal cannula. Diabetes meds will be: Humulin N 64 U a.m., Humulin N 36 U p.m. and Humalog sliding scale: Accu-Chek Accu-Chek Accu-Chek Accu-Chek
Activity:
Follow-Up:
less than 100 101 - 130 131 - 170 117 - 220
= = = =
0, 3, 5, 8,
Accu-Chek Accu-Chek Accu-Chek
221 - 300 301 - 400 less than 400
= = =
12, 15, 18.
As tolerated.
Mr. Newman has an appointment to see me in the office in approximately
two weeks for recheck. He should call or come in sooner if he has any questions or problems prior to that appointment.
I have read the above instructions and received a copy of them. They were explained to me and all my questions were answered satisfactorily.
Edward C. Newman Patient's Signature
8/14/xx Date
a.m.
6:45 p.m.
William J. Wainwright
Time
DISCHARGE INSTRUCTIONS SHEET © 2003. American Health Information Management Association. All rights reserved.
Attending Physician
Sundance Medical Center Painted Valley, USA Date/ Time
8/14
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502 Progress Notes
Orders
Admit to CCU per Dr. Wainwright. DX: CHF, COPD. Condition stable Vitals q.4h. while awake, daily weight.
78 y.o. male with severe COPD, IDDM, ASHD admitted with increased dyspnea. See H&P. Wainwright
William J. Wainwright 0010
ALL: PCN -> Hives Diet - No added salt Activity Up to BR IV saline lock Meds: Lasix 80 mg IV now Humulin N 64 U SQ q.a.m. Humulin N 36 U SQ q.p.m. Humalog 12 U AC t.i.d. Hold if BS <120 Theo-Dur 200 mg p.o. b.i.d. Lasix 160 mg p.o. b.i.d. EC ASA 1 p.o. daily Imdur 60 p.o. q.h.s. Diazepam 10 mg p.o. q.h.s. Clorazepate 15 mg q.h.s. nitroglycerin 0.4 mg SL p.r.n. chest pain Pilocarpine 4% ophthalmic drops 1 drop O.D. q.i.d.
0011
O2 - keep sats above 88%
William J. Wainwright 0012
Albuterol nebs q.i.d. p.r.n. O2 William J. Wainwright
Form # _ _ _ _
Physician Orders and Progress Notes
© 2003. American Health Information Management Association. All rights reserved.
William J. Wainwright
Sundance Medical Center Painted Valley, USA Date/ Time
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502 Progress Notes
Orders
8/15
LAB: CBC, CMP, theo level, UA, TSH Lisinopril 20 mg p.o. q.a.m. EKG üdone ER CXR state, check if done ER P-8 in a.m. 8/15 Oximetry daily while on O2 Foley to gravity William J. Wainwright
8/15
May request Valium 10 mg q.h.s. p 3 hr p.m. x1 Accu-Chek q.i.d. EKG in a.m. Atrovent inhaler two puffs q.i.d.
Progress Note: 8/15 Social Services report from yesterday indicated pt currently uses no services. Will follow. W. Scarlett, MSW
William J. Wainwright 8/15
8/15
Change Atrovent inhaler to SVN’s q.i.d. v.o. Dr. Wainwright/rla William J. Wainwright @ 0945 < 101 131 171 221 301
Humalog q.i.d. S.S. 100 = 0 130 = 170 = 220 = 300 = 400 =
3 5 8 12 15
D/C H.s. Chlorazepate Inc Diazepam to 20 mg p.o. q.h.s. Ativan 2 mg p.o. t.i.d. p.r.n. anxiety Up walking William J. Wainwright
8/15 Breathing easier 110/60, P 80 Lungs clear, distant BS Heart - regular Abd soft Ext no edema Weight down 6 # - CHF - IDDM Increase activity Monitor O2 sats Dr. Wagner
William J. Wainwright 8/15
@ 1410 D/C Humalog 12 u a.c. t.i.d. T.O. Sally Mertz, RPO Sall;y J. Mertz, RPO
Form # _ _ _ _
Physician Orders and Progress Notes
© 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Painted Valley, USA Date/ Time
8/16
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502 Progress Notes
Orders
@ 0650 MOM 30 cc p.o. QP p.r.n. S.O. Dr. Wainwright, A. May, RN
William J. Wainwright 8/16
D/C Foley, D/C CCU, D/C IV
William J. Wainwright 8/16
Discharge Meds: Humulin N 64 U a.m. Humulin N 36 U p.m. Humalog sliding scale Accu-Chek
William J. Wainwright
Units < 100 = 0 101 130 = 3 131 170 = 5 171 220 = 8 221 300 = 12 301 400 = 15 > 400 = 18 Diazepam 20 mg p.o. q.h.s. albuterol & Atrovent SVN’s q.i.d. & p.r.n. Lasix 160 mg p.o. b.i.d. Theo-Dur 200 mg q.a.m., 300 mg q.h.s. Imdur 30 mg (1/2 tab) q.h.s. Pilocarpine 4% 1 drop O.D. q.i.d. nitroglycerin 0.4 mg SL p.r.n. chest pain O2 2 to 4 L/m N.C. Appt. my office - 2 wks
William J. Wainwright
Form # _ _ _ _
Physician Orders and Progress Notes
© 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Painted Valley, USA
Newman, Edward C. Dr. William J. Wainwright
Date/ Time
Nursing Progress Notes
Coronary care unit # 012502
8/14/xx 0805 Admission Admitted to CCU-3 per w/c from ER. Settles into bed with no c/o @ present. See admission sheet. HRM, RN Brenda Kellye, RN
Brenda Kellye, RN
0845
Foley catheter inserted. Tolerated well.
0900
Lisinopril 20 mg p.o. now given per order, Lasix 80 mg IV now given per order.
Brenda Kellye, RN 1000
Visiting with wife in room. No c/o at present.
Brenda Kellye, RN
1300
Dozing in bed quietly.
Brenda Kellye, RN
1500
Visiting in room with family. No c/o.
Brenda Kellye, RN
1900
Summary Appetite good. Denies pain. Resting quietly. Wife @ bedside. Rhythm unchanged.
2200
Summary Uneventful evening, denies pain. Does become SOB with activity, respirations easy @ rest. No c/o. Leslie Scorch, RN
Leslie Scorch, RN
8/15/xx 0115 SOB Resting awake in bed, had “Charley Horse” in leg. Better now, but dyspneic, resp 30/m et breathing rapidly, feels winded. LS dim throughout with left base crackles. Patient quite anxious. Robert K. Russo, RN
Robert K. Russo, RN
0115
SVN with albuterol 0.5 cc given.
0130
Breathing easier, increased air exchange throughout. Lungs fields with bibasilar crackles now. Feeling better, remains anxious. Robert K. Russo, RN
0150
Valium 10 mg p.o. repeated
0600
Awakened for assessment, had been sleeping. Becomes dyspneic on exertion with mild dyspnea with rest. LS remains dim throughout. Crackles lower 1/2 left and 1/4 left. Admits to feeling SOB, wants treatment. Robert K. Russo, RN
Robert K. Russo, RN
Nursing Progress Notes © 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Sundance Medical Center Painted Valley, USA
Dr. William J. Wainwright
Date/ Time
Nursing Progress Notes
Coronary care unit # 012502
8/15/xx
Robert K. Russo, RN
0615
SVN given with albuterol and atrovent
0625
Feeling better after treatment. Increased air exchange to lung fields though crackles remain, still has c/o feeling slightly SOB. Robert K. Russo, RN
0630
Lasix 160 mg p.o. given
0800
Resting well. Upon awakening slightly SOB. Sats 91-92% on 2 liters. Dim LS with faint bibasilar crackles. BS pos, Abd. neg. Ext. no edema. VS stable. Patient alert & oriented.
Robert K. Russo, RN
Brenda Kellye, RN 0830
Wife here. Patient eating. No c/o.
Brenda Kellye, RN
1000
Resting now. Resp. more at ease.
Brenda Kellye, RN
1030
Explained new S.S. insulin to patient and wife. No c/o, questions.
Brenda Kellye, RN Brenda Kellye, RN
1230
Stable. Resting. Resp. easy.
1300
Tried pt on 1L O2/NC, sats decrease to 87%. Increased to 2L/NC, sats 95%. Amb with 2LO2, 2 assist & Sat monitor on, 100 Fahrenheit. Sats to 92%. Back to room & up in chair. Did get slightly dyspneic with amb. More rested in chair. Sats back up 95% when sitting.
Anne Odinson, RN
1400
Back to bed with 2LO2. Sats 98%. No c/o. Restful. Lights out for a bit. Call light placed.
1450
Resting with easy, snoring like resp. Wife in room.
1600
Pt awake & talkative. Denies any discomfort. Resp easy at rest. Still has coarse rales in bases bilaterally. Color pink. Sats in mid 90’s on 2L. No pedal edema. C/o some weakness.
Anne Odinson, RN Anne Odinson, RN
Leslie Scorch, RN
Nursing Progress Notes © 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Sundance Medical Center Painted Valley, USA
Dr. William J. Wainwright
Date/ Time
Nursing Progress Notes
Coronary care unit # 012502
8/15/xx 1830 Appetite good. Assisted to ambulate 100 ft in hall with 2 assist & cont O2. Only slight staggered steps at times. Otherwise gait steady. To BR but unable to have BMO. Passed flatus. Had prune juice with supper. Leslie Scorch, RN 1930
VSS, resting quietly, denies physical c/o. Lungs diminished BS, O2 decreased 1/4 lit with some crackles, dec 1/4 lit SO2 96% @ 2L/NC. Re AP, inc pulses x 2, no c/o. Soft abd, Pos BS x 4, Foley patent with clear yellow urine. Leslie Scorch, RN
2030 2050
Bath done, cares done. Linen changed. Leslie Scorch, RN Accu ü Accuü 105, pt given Humalog 3 units. Pt h.s. snack.
2105
SVN
Leslie Scorch, RN
SVN with V.S. Albuterol & Atrovent given, tolerated well.
Leslie Scorch, RN
8/16/xx 0200 Sleeping in bed, breathing easily.
Robert K. Russo, RN
0115
SVN with albuterol 0.5 cc given.
Robert K. Russo, RN
0130
Breathing easy, good air exchange. Lungs fields with only minor crackles. No c/o at this time. Robert K. Russo, RN
0640
Feels better after treatment. Improving air flow in all lung fields. Foley catheter removed. IV discontinued. Robert K. Russo, RN
0700
Up to BR, voids well.
0800
Dr. Wainwright visits, discharge order written and discharge instructions given. Patient resting well. Blood sugar 130, vital signs stable. Ext. no edema. VS stable. Patient alert & oriented.
Robert K. Russo, RN
Brenda Kellye, RN 0830
Wife here. Patient eating. No c/o. Breakfast, eats well, somewhat short of breath while eating, otherwise no dyspnea, no c/o. Brenda Kellye, RN
Nursing Progress Notes © 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Painted Valley, USA Date/ Time
Nursing Progress Notes
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502
8/16/xx 1045 Discharge instructions discussed with patient and wife. They voice understanding. Will follow up with Dr. Wainwright at his office in two weeks. Brenda Kellye, RN 1115
Discharged per wheelchair, escorted to car.
Nursing Progress Notes © 2003. American Health Information Management Association. All rights reserved.
Brenda Kellye, RN
Sundance HealthCare Systems Patient Family Name
Painted Valley, USA
First Name
Newman,
Age
Edward C.
Room No.
78
CCU #2
Attending Physician
Date
Dr. William J. Wainwright Component
8/14/xx
Normal Date
Color Character Spec Gravity Leukocytes Nitrates
Yellow Clear 1.020 or less Negative Negative
PH Protein Urine Glucose Urine Ketones Urine
5-6 Negative Negative Negative
Urobilinogen Bilirubin Urine Occ Blood Urine WBC/HPF RBC/HPF Epitheial Casts/LPF Crystals Amorphorus Mucous Yeast Cells Bacteria
0 - 1 mg/dl Negative Negative 0-5 0-5
# 012502 Lab. No.
7734-2002
Second
Third
Fourth
Y / N
Y / N
Y / N
Yellow Clear 1.015 Negative Negative 5.2 Negative Negative Negative Negative Negative Negative 3-5 Few 15-20 Hylalin
Negative Negative
Sent for Culture: 24 Hour Urine
First 08/14/xx
Hosp. No.
Y / N 0 - 30
for Microalbumin
Form L-9001 (5/01) pa
URINALYSIS
© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502
Diagnosis: CHF, COPD Allergies: Penicillin Medication and Date of Order
Hosp Day Hosp Day Hosp Day Hosp Day 8/15 # 8/16#3 #4
Route 8/14 #1
1.
Lisinopril 40 mg p.o. q.a.m.
08
SMB
SGA
2.
Theo-Dur 200 mg p.o. b.i.d.
08
ams
SMB
21
nmr
kl
08
ams 1200
SMB
KJN
17
pvm
rlw
KJN KJN
3. 4.
Lasix 160 mg p.o. b.i.d.
5. 6.
EC ASA 1 p.o. daily
08
ams
SMB
7.
Imdur 60 p.o. q.h.s.
21
nh
kl
8.
Diazepam 10 mg p.o. q.h.s.
21
nh
9.
Pilocarpine 4% 1 gtt OD q.i.d.
08
/
SMB
10.
12
pvm
SMB
11.
16
mds
swb
12.
21
taf
ko
see D’s below
13.
Clorazepate 15 mg q.h.s.
21
wlk
dcd 8/15
14.
Diazepam 20 mg p.o. q.h.s.
21
/
ko
15. 16. 17. 18. 19. 20.
MEDICATION PROFILE
© 2003. American Health Information Management Association. All rights reserved.
KJN
KJN
Sundance HealthCare Systems Patient Family Name
Newman,
Painted Valley, USA
First Name
Age
Room No.
Edward C.
78
CCU #2
Attending Physician
Date
Dr. William J. Wainwright Component
8/14/xx
Normal Date
First 08/14/xx
Chemistry 10 Sodium Potassium Chloride CO2 Glucose BUN Creatinine Total Bili Albumin Calcium
135 3.5 100 23 80 12 0.6 0.0 3.5 8.2
-
145 5.3 110 29 116 20 1.3 1.3 5.0 10.1
143 4.4 100 35 238 27 1.5 0.7 3.9 9.8
ALP AST ALT Total Protein
56 0 14 6.0
-
112 27 26 8.0
58 21 18 6.6
Theo TSH
10.0 - 20.0 0.4 - 6.2
8.2 1.9
Lipid Profile Total Choles HDL LDL Triglycerides
100 40 66 50
-
H H H H
Second 08/15/xx
143 3.8 100 36 91 35 1.6
9.4
L
200 80 130 150
HG A1C
4.0
- 6.0
PSA
0.0
- 4.0
Form L-9003 (5/01) pa
CHEMISTRY
© 2003. American Health Information Management Association. All rights reserved.
H H H
Third
Hosp. No.
# 012502 Lab. No.
7734-2002 Fourth
Sundance HealthCare Systems Patient Family Name
Newman,
Painted Valley, USA
First Name
Age
Room No.
Edward C.
78
CCU #2
Attending Physician
Date
Dr. William J. Wainwright Component
8/14/xx
Normal Date
Hematology WBC (x 103) RBC (x 103) Hgb (g/dl) HCt (%) MCV (x 103) MCH (x 103) MCHC (%) PLT (x 103) Differential Band Seg Lymph Mono Eosin Baso NRBC Atyp Lymph Meta Myelo Pros Blast
M/F
4.3 - 11.0
M
4.6 - 6.2
F
4.2 - 5.4
M F M F
12 12 40 36
First 08/14/xx
10.4 4.25 13.6
M F M/F M/F
80 - 94
95.7
M/F
150 - 375
H
18 16 54 47
0 46 13 4 0 2
-
Second
40.6
82 - 100
26 - 33 31 - 36
-
Form L-9003 (5/01) pa
6% 82% 37% 12% 5% 2%
32.0 33.4
76 15 4 3 3
H
HEMATOLOGY
© 2003. American Health Information Management Association. All rights reserved.
Third
Hosp. No.
# 012502 Lab. No.
7734-2002 Fourth
Sundance HealthCare Systems Painted Valley, USA
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502
CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: This patient is a 78-year-old resident of Podunk Center. He has a long-standing history of severe COPD, insulin-dependent diabetes mellitus and ASHD and status post MI’s. According to the patient he has been severely short of breath over the past several months. Apparently this has increased over the past two days and yesterday it severely limited his ability to get up and walk around. During the night last night, at approximately 5:00 a.m., he had a severe episode of shortness of breath. He received two nebulizer treatments and his wife turned his home oxygen up wide open. Despite this, however, he remained severely short of breath. His wife then called 911 and he was brought to the ER via ambulance. The patient denies substernal chest pain. He states that he has gained approximately five pounds over the past couple of weeks. He also admits to swelling of both ankles at the end of the day. PAST MEDICAL HISTORY: Several episodes of COPD in the past. He has also been admitted with MI’s at age 66 and again in September, three years ago. He has had congestive heart failure and long-standing insulin-dependent diabetes mellitus. He has glaucoma and chronic blindness in his right eye. He has a history of long-standing noncardiac chest pain. He has also had peptic ulcer disease. PAST SURGICAL HISTORY: He is status post T&A, hemorrhoidectomy x 2, colonoscopy with polypectomy in six years ago which revealed a tubular adenoma, right inguinal herniorrhaphy four years ago, another colonoscopy repeated three years ago. He had a TURP in 1981 for benign prostatic hypertrophy. MEDICATIONS: Humulin N 64 units in the morning and 64 units in the evening. Humalog sliding scale t.i.d., usually taking 14 to 16 units at mealtimes. He also takes Theo-Dur 200 mg b.i.d., Lasix 160 mg a.m. and 80 mg at noon q.d. Ecotrin 325 mg q.d. Pilocarpine 4% ophthalmic drops 1 drop right eye q.i.d., Imdur 60 mg q.h.s., Diazepam 10 mg q.h.s., Clorazepate 15 mg q.h.s., nitroglycerin 0.4 mg sublingual p.r.n. chest pain, albuterol and Atrovent nebulizer q.i.d. and p.r.n. He is on home O2 routinely at 2 liters per minute per nasal cannula. ALLERGIES: Penicillin causes a rash. HABITS: 150 pack year history of cigarette smoking. He is currently a nonsmoker, does not drink alcohol. FAMILY HISTORY: The patient is married and is a retired teacher. He lives in Podunk Center with his wife who also has had some health problems, including atrial fibrillation. They have three children in the area. REVIEW OF SYSTEMS: General: No seizures or syncope. He has had the weight gain as mentioned above. HEENT: No recent change in hearing or vision. He does have the glaucoma as mentioned above. Dr. Signature Form 9427 (8/00) mr
HISTORY & PHYSICAL
© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502
Respiratory: As above. Cardiac: See HPI. GI: No nausea, vomiting, diarrhea, constipation, hematochezia or melena. GU: No burning, hematuria or recent UTI. He states that he does have nocturia one to two times per night. Musculoskeletal: Negative. Neurologic: He has been depressed over his breathing difficulties. PHYSICAL EXAMINATION: General: This is a well-developed, well-nourished 78-year-old white male, sitting up on the examining table with oxygen running. He appears in no acute distress at this time. Vital Signs: Blood pressure 144/72, pulse 108, respirations 38, temperature 96.4 degrees Fahrenheit. Weight 190 pounds. Skin: Anicteric, warm and dry. Face is slightly flushed at this time. Heent: Shows clear TMs. Pupils equal, round and reactive to light on the left. There is evidence of corneal dystrophy on the right. Oropharynx is clear. Neck: Supple, no cervical lymphadenopathy. Chest: Lungs have slight crackles in the right mid-lung field and base, clear on the left. Heart: Regular rate and rhythm without murmur or gallop. Abdomen: Normal bowel sounds, soft and nontender. No masses, hernias or organomegaly noted. Genitalia: External genitalia is normal. Extremities: Warm and well perfused. There is trace edema bilaterally. Pedal pulses are palpable. Neurologic: Motor and strength are 5/5 bilaterally. DTRs are symmetrical. Psych: Affect is more flat than typically seen. Recent and remote memory are good. Judgement and insight are intact. Does seem to be slightly depressed. LABS: Chest x-ray shows cardiomegaly and evidence of vascular redistribution consistent with CHF. EKG shows normal sinus rhythm at a rate of 94 beats per minute. There is evidence of an old anterior MI and an old inferior MI. No acute appearing ST-T wave changes. Sodium is 143, potassium 4.4, BUN 27, creatinine 1.5, glucose 238. CBC shows white count 10,400 with a normal differential, hemoglobin 13.6, hematocrit 37.9. ASSESSMENT: 1. A 78-year-old white male with cor pulmonale and congestive heart failure secondary to his severe chronic obstructive pulmonary disease and coronary artery disease. 2. Arteriosclerotic heart disease with history of previous myocardial infarctions and congestive heart failure. 3. Chronic glaucoma with right eye blindness. 4. Chronic insomnia. 5. Insulin-dependent diabetes mellitus. 6. Benign prostatic hypertrophy, status post transurethral resection of prostate. PLAN: The patient will be admitted to the CCU. Monitor his O2 saturations, provide oxygen as necessary and diurese him. Dr. William J. Wainwright Signature D&T: 8/14/xx Form 9427 (8/00) mr
HISTORY & PHYSICAL
© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
Date Time
Newman, Edward C. Dr. Dr. William J. Wainwright Coronary care unit # 012502
08/14 _____________
08/15 _____________
08/16 _____________
_____________
3 6 9 12 15 18 21 24
3 6 9 12 15 18 21 24
3 6 9 12 15 18 21 24
3 6 9 12 15 18 21 24
105 ................................................................................................................................................... 104 ................................................................................................................................................... 103 ................................................................................................................................................... 102 ................................................................................................................................................... 101 ................................................................................................................................................... 100 ................................................................................................................................................... 99
...................................................................................................................................................
98
...................................................................................................................................................
97
...................................................................................................................................................
96
...................................................................................................................................................
95
...................................................................................................................................................
Pulse
93
102
89
88
86
76
Resp.
38
20
21
24
20
18
B/P
143 72 144 62 136 74 ___/___| 140 78 ___/___| 110 60 122 76 122 78 ___/___| ___/___ ___/___| ___/___| ___/___ ___/___| ___/___| ___/___ ___/______/___| ___/___| ___/___| ___/___ ___/___| ___/___| ___/______/___| ___/___| ___/___ ___/___| ___/___| ___/___
In ______| ______| ______ Out ______| ______| ______
Weight:
195.7 194.9 ______ | _______
ADA ______ ADA Diet ______| ______| Good ______ Fair ______|
Appetite ______|
______| ______| ______ ______| ______| ______
193.3 192.6 ______ | _______
ADA ______| ADA ADA ______| ______ Fair Good Good ______| ______| ______
______| ______| ______ ______| ______| ______
190.4 | _______ ______
ADA ______| ______ ______| Fair ______| ______| ______
GRAPHIC SHEET © 2003. American Health Information Management Association. All rights reserved.
______| ______| ______ ______| ______| ______
______ | _______
______| ______| ______ ______| ______| ______
Sundance HealthCare Systems Painted Valley, USA Street Address
Patient's Name
Newman, Edward C. Birth Date
Age
04/01/xx
Phone Number
Devils Lake
Marital Status
M
# 012502
City
78
Sex
Hospital Number
2720 Mountain View
701
State
Married
Zip
N.D.
Soc. Sec. #
County
58301
Ramsey
CCU #2 Race
Religion
504-59-3132
Methodist
W Ethnicity
Patient's Occupation
Teacher (Retired) Notify In Emergency
801-7734
Room
Non-Hispanic Name
Relationship
Mildred
Responsible for Account
Wife
Address
Self
Phone No.
2720 Mountain View, Devils Lake Date Admitted
Time
8/14/xx
0645
701 AM PM
801-7734
Date Discharged
08/16/xx
Time
1111
AM PM
Name & Address of Any Institution From Which Discharged in Last 60 Days
Date of Last Admission
2/29/xx
N/A Consultant
Admitting Physician
Dr. William J. Wainwright Aitemding Physician
Dr. William J. Wainwright ICD-9-CM CODES
Admitting Diagnosis (Within 24 Hours)
Cor pulmonale and congestive heart failure secondary to severe chronic obstructive pulmonary disease and coronary artery disease. Principal Diagnosis
1.
Congestive heart failure complicating severe chronic obstructive pulmonary disease.
Secondary Diagnoses
2. 3. 4.
Arteriosclerotic heart disease with history of myocardial infarctions. Insulin-dependent diabetes mellitus. Glaucoma.
Complications
Operative Procedures (Date & Title)
ü
Discharged Alive ____
Died ____
Autopsy Yes ____
No ____
William J. Wainwright
Physician Signature
ADMISSION SUMMARY SHEET This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental. © 2003. American Health Information Management Association. All rights reserved.
CONDITIONS OF ADMISSION 1. CONSENT TO HOSPITAL CARE I am presenting myself for admission to St. Jude’s Medical Center. I voluntarily consent to the rendering of medical care which is determined to be necessary or beneficial in the professional judgement of my physician. This includes routine diagnostic procedures and medical treatment by authorized agents and employees of the Hospital, and by its medical staff, or their designees. I acknowledge that no guarantees have been made to me as to the effect of such examination or treatment on my condition. 2. AUTHORIZATION TO RELEASE INFORMATION I authorize St. Jude’s Medical Center to release such information from my medical record as may be necessary for the completion of the hospital’s or my physician’s claims for reimbursement to my insurance company or agency. I UNDERSTAND THAT DISCLOSURE MAY INCLUDE DIAGNOSES AND OPERATIONS OR PROCEDURES PERFORMED AND THAT, AT THE REQUEST OF MY INSURANCE COMPANY OR AGENCY, MY COMPLETE MEDICAL RECORD MAY BE SUBJECT TO REVIEW. IN ADDITION, I UNDERSTAND THAT COPIES OF MY RECORD MAY BE OBTAINED BY MY INSURANCE COMPANY OR AGENCY. 3. ASSIGNMENT OF BENEFITS In consideration of the services received or to be received for this admission to St. Jude’s Medical Center, I assign all insurance benefits due me. I further warrant that the hospital shall be entitled to the full amount of its charges. Any credit balance resulting for any reason will be applied to other existing accounts. This also assigns benefits to Anesthesia Consultants, PC. I hereby agree to pay any and all hospital charges that exceed or that are not covered by my hospitalization insurance coverage. This assignment shall be irrevocable. 4. VALUABLES DISCLAIMER I understand that St. Jude’s Medical Center maintains a safe for the safekeeping of money and valuables. I, also, understand that I assume full responsibility for any and all of my valuables, money, clothing, dentures, and other personal items while a patient in the hospital unless deposited with the Hospital for safekeeping. Valuables Deposited with the Hospital
ü
YES
NO
5. REQUEST FOR FACILITY ACCOMMODATIONS I agree to pay to the Hospital any difference between the semi-private rate provided by my hospitalization insurance and the Hospital charges for a private accommodation. I understand that private accommodations are more expensive than the room rate payable by my hospitalization insurance and that it is my responsibility to pay the difference. I request a Private Room
YES
ü
NO
This document has been fully explained to me, and I certify that I understand its contents and agree to it freely.
August 14, xx DATE
0645 TIME
AM PM
Edward
C.
Newman
Patient or authorized person
Marilyn Flemming Witness
Relationship Guarantor/Insured Certificate Holder
Signature is not that of the patient because: ( ) patient is a minor ( ) other reason (specify):
Sundance HealthCare Systems Painted Valley, USA Patient's Name
Street Address
Hospital Number Phone Number
Birth Date
Age
City
Sex
Marital Status
State
Soc. Sec. #
Zip
County
Race
Religion
Ethnicity
Patient's Occupation Notify In Emergency
Name
Relationship
Address Date Admitted
Room
Responsible for Account
Phone No. Time
AM PM
Date Discharged
Time
AM PM
Date of Last Admission
Name & Address of Any Institution From Which Discharged in Last 60 Days
Admitting Physician
Consultant
Aitemding Physician
ICD-9-CM CODES
Admitting Diagnosis (Within 24 Hours)
Principal Diagnosis
Secondary Diagnoses
Complications
Operative Procedures (Date & Title)
Discharged Alive ____
Died ____
Autopsy Yes ____
No ____ Physician Signature
ADMISSION SUMMARY SHEET This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental. © 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA Patient's Name:
Last Name
EMERGENCY ROOM / OUTPATIENT RECORD Account Number:
First Name
Newman,
Edward
Address:
C.
State
Devils Lake
Employer: Address: Responsible Party: Address:
Alfred E. Newman Devils Lake, ND
Name of Insurance Company Address of Insurance Co.
Home Phone
58301
Age
08/14
Sex
78
a.m. p.m.
Admission Date
701 801-7734 Zip
N.D.
Retired Tokyo, ND
Notified:
Middle Initial
Date of Birth
Civil Status
M 04/01 Teacher Occupation:
Medicare Hooterville, ND
Policy No.
# 012502 Religion
Methodist 504-59-3132 Soc. Sec. #
S M W D Sep
Phone No: Occupation: Phone No:
Med.Rec. Number
Notify Press
Yes
No
Teacher 801-7734
Family Doctor: Dr. Wainwright Notified Yes No
AP 504-39-3132
Brought In By: ___ Police ___
Relative
Mildred
Relationiship:
Wife
By Whom
Police
No
Coroner
No
Time
Agathie Chrsty
0645
Relative
___ xx ___
Self Fire
___
Other
Race: Ethnicity:
a.m./p.m.
BRIEF HISTORY: (If accident, state where, when & how injured; if illness describe) :
78-year-old male to ER per ambulance. Awoke at 0600 with acute respiratory distress. Hx COPD. Did home nebulizers without relief. Ambulance called for transport. Second neb started et finished en route. Accu ü done also “200”. Currently mildly dyspneic, respirations 38, lungs slightly et moderate diminished. SAO2 98% on 2 liter p.m. NC. ??? Rhythm NS without ectopics. 0725 Saline lock 22 g 28 mm Jelco started L hand - Lasix 80 mg IV push. Lock flushed per protocol NUB. 0730 Dr. Wainwright in to examine patient. 0740 Admit Coronary care unit . 0810 Patient to floor in W/C per RN
Allergies: Penicillin
Patient Medications: See attached sheet. PHYSICIAN'S REPORT: History & Physical Findings:
Condition on Admission: Good Poor
____ ____
Coma ____ Vital Signs:
Fair Shock
____ xx ____
Hemorrhage
____
home O2. O2 sat on 2LNC 96%
Pulse increased,
Adm H:
CHF
RR 28 pm
ASHD
Heart: WNL.
Resp. B.P.
96.4 ____ 108 ____ 48 ____ 143 72 ____/____
Normal
Other
System Inventory:
o o
o o
Mental/Emotional Status:
ü o
o
Skin
ü o
Respiratory
o
Cardiovascular.
Referred to Dr.
o
Musculoskeletal:
Instructions to Patient:
o
Gastrointestinal
o
Genitourinary
o
Neurological
Temp. Pulse
o
ü o ü o ü o ü o ü o
ü o o Form # _ _ _ _
EENT
Height: 72" Weight: 190 SAO2 96%
Increasing shortness of breath 6:00 a.m. No chest pain. No cough. Has been on
Diagnosis:
Lungs: Expiratory wheezes bilaterally. Lower extremity edema 1+.
Treatment (including medications):
Disposition of Case:
Admitted to CCU, LAB: CXR, EKG, CBC, PO2 (Theo Old charts
per Dr. Wainright / Ries RN)
Edward C. Newman
A: Acute exacerbation of asthma / LVF. Lasix 20 mg IV Date: P: Admit to CCU.
8/14/xx
Patient's Signature
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Date
6:45 Time
William J. Wainwright Attending Physician
PATIENT:
DATE:
A.M. P.M.
DATE:
1. I, (or
)
acting for
)
knowing that I, (or ) am (is) suffering from a condition requiring emergency or out patient care do hereby voluntarily consent to such care encompassing diagnostic procedures and medical treatment by Dr. his assistants or his designees as is necessary in his judgement. 2.
I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatments or examination in the hospital.
3.
This form has been fully explained to me and I certify that I understand its contents.
Witness
Signature of Patient
(If patient is unable to consent or is a minor, complete the following): Patient (is a minor years of age) is unable to consent because
Witness
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Closest Relative or Legal Guardian
Sundance HealthCare Systems Painted Valley, USA Patient's Name:
Last Name
EMERGENCY ROOM / OUTPATIENT RECORD Account Number:
First Name
Address:
Middle Initial
State
Zip
Home Phone
Admission Date
Age
Date of Birth
Sex
a.m. p.m.
Med.Rec. Number
Civil Status
Religion
S M W D Sep
Employer: Address:
Occupation: Phone No:
Soc. Sec. # Notify Press
Responsible Party: Address:
Occupation: Phone No:
Family Doctor: Notified
Policy No.
Brought In By: ___ Police
Name of Insurance Company Address of Insurance Co. Notified:
___
Relative
Relationiship:
By Whom
Police
Coroner
Time
Relative
Yes
No
Yes
No
___ ___
Self Fire
___
Other
Race: Ethnicity:
a.m./p.m.
BRIEF HISTORY: (If accident, state where, when & how injured; if illness describe) :
PHYSICIAN'S REPORT: History & Physical Findings:
Condition on Admission: Good Poor
____ ____
Coma ____ Vital Signs:
Fair Shock
____ ____
Hemorrhage
____
Temp. Pulse
____ ____
Resp. B.P.
____ ____/____
Normal
Other
System Inventory:
o o
o o
Mental/Emotional Status:
o
o
Skin
o
o
Respiratory
o
o
Cardiovascular.
Referred to Dr.
o
o
Musculoskeletal:
Instructions to Patient:
o
o
Gastrointestinal
o
o
Genitourinary
o
o
Neurological
o o Form # _ _ _ _
Diagnosis:
Treatment (including medications):
Disposition of Case:
Date:
EENT Patient's Signature
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Date
Time
Attending Physician
Sundance HealthCare Systems Painted Valley, USA
NEWMAN, Edward C.
# 012502
Age 78
CCU
Dr. D. J. Wagner
8-14-xx
a.m.
MECHANISM:
Normal sinus rhythm
RATE:
94 beats per minute
AXIS
Left axis deviation. P-R-T axes 68 - 55 116
PW:
Are broadened. P-R interval 162 ms
COMPLEXES:
Normal voltage. Left ventricular hypertrophy with QRS widening. Left atrial enlargement. QT/Qtc 317/398 ms. QRS interval is 118 ms.
TW:
Nonspecific ST and T-wave abnormality.
COMMENT:
Abnormal EKG, possible lateral ischemia. Old anterior MI. No change from previous EKG.
DJW/bg St. Luke’s D&T: 8-14-xx
Donald J. Wagner Cardiologist Signature Form 4101
(10/01) mr
ELECTRCARDIOGRAM
© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
NEWMAN, Edward C. Dr. William J. Wainwright Coronary care unit # 012502
DISCHARGE SUMMARY: This patient is a 78-year-old gentleman from Podunk Center. He was admitted because of increasing problems associated with his chronic congestive heart failure, COPD, diabetes and ASHD. The patient was experiencing increasing dyspnea associated with the CHF. He was given an IV and increased dose of Lasix. Following this the patient diuresed approximately five pounds during his hospitalization. Both his O2 saturations and breathing steadily improved. Two days after admission he was feeling much better. He had been up walking and was having no chest pain. He is being discharged in improved condition. DISCHARGE MEDICATIONS: Diazepam 20 mg p.o. q.h.s., albuterol and Atrovent nebulizers q.i.d. and p.r.n., Lasix 160 mg p.o. b.i.d.; TheoDur 200 mg q.a.m., 300 mg q.h.s.; Imdur 30 mg (1/2 tab) q.h.s., Pilocarpine 4% 1 drop O.D. q.i.d., nitroglycerin 0.4 mg sublingual p.r.n. chest pain, oxygen 2 to 4 liters per minute per nasal cannula. For his diabetes he will be on Humulin N 64 U a.m., Humulin N 36 U p.m. and Humalog sliding scale as follows: Accu-Chek less than 100 = 0, Accu-Chek 101 - 130 = 3, Accu-Chek 131 - 170 = 5, Accu-Chek 171 - 220 = 8, Accu-Chek 221 - 300 = 12, Accu-Chek 301 - 400 = 15, Accu-Chek more than 400 = 18. FOLLOW-UP: Mr. Newman has an appointment to see me in the office in approximately two weeks for recheck. He should call or come in sooner if he has any questions or problems prior to that appointment. He is to check his weights on a daily basis at home and if he gains more than two pounds from his discharge weight he is to call me at once or come into the ER or walk-in clinic. FINAL DIAGNOSIS: 1. Congestive heart failure complicating severe chronic obstructive pulmonary disease. 2. Arteriosclerotic heart disease with history of myocardial infarctions. 3. Insulin-dependent diabetes mellitus. 4. Glaucoma. PROCEDURES: None. COMPLICATIONS: None.
William J. Wainwright
DJW/sgs D&T: 8/16/xx Form 9055 (3/98) him
DISCHARGE SUMMARY
© 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
X-RAY NO.
47932
DOCTOR
Dr. W. J. Wainwright
DATE
8/14/xx
REGION EXAMINED
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502
CHEST X-RAY
Indications: SOB CHEST:
There is mild to moderate pulmonary vascular congestion. There is mild bilateral interstitial edema. The findings are less prominent than on 1-1-xx. No focal consolidation is seen in the lungs.
WCR/smb
William C. Roentgen RADIOLOGIST'S SIGNATURE
© 2003. American Health Information Management Association. All rights reserved.
M.D.
Sundance Medical Center Painted Valley, USA
Patient Name: Newman, Edward C. Physician: Dr. William J. Wainwright Room No. Coronary care unit
# 012502 Instructions: Please follow the instructions given below. This is an important part of your continued recovery. If, after reading the instructions, you have any questions please ask your physician/nurse for clarification. 1500 calorie ADA, no added salt diet.
Diet:
Medications:
Diazepam 20 mg p.o. q.h.s., albuterol and Atrovent nebulizers q.d. and p.r.n., Lasix 160
mg p.o. b.i.d.; Theo-Dur 200 mg q.a.m., 300 mg q.h.s.; Imdur 30 mg (1/2 tab) q.h.s., Pilocarpine 4% 1 drop O.D. q.i.d., nitroglycerin 0.4 mg sublingual p.r.n. chest pain, oxygen 2 to 4 liters per minute per nasal cannula. Diabetes meds will be: Humulin N 64 U a.m., Humulin N 36 U p.m. and Humalog sliding scale: Accu-Chek Accu-Chek Accu-Chek Accu-Chek
Activity:
Follow-Up:
less than 100 101 - 130 131 - 170 117 - 220
= = = =
0, 3, 5, 8,
Accu-Chek Accu-Chek Accu-Chek
221 - 300 301 - 400 less than 400
= = =
12, 15, 18.
As tolerated.
Mr. Newman has an appointment to see me in the office in approximately
two weeks for recheck. He should call or come in sooner if he has any questions or problems prior to that appointment.
I have read the above instructions and received a copy of them. They were explained to me and all my questions were answered satisfactorily.
Edward C. Newman Patient's Signature
8/14/xx Date
a.m.
6:45 p.m.
William J. Wainwright
Time
DISCHARGE INSTRUCTIONS SHEET © 2003. American Health Information Management Association. All rights reserved.
Attending Physician
Sundance Medical Center Painted Valley, USA Date/ Time
8/14
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502 Progress Notes
Orders
Admit to CCU per Dr. Wainwright. DX: CHF, COPD. Condition stable Vitals q.4h. while awake, daily weight.
78 y.o. male with severe COPD, IDDM, ASHD admitted with increased dyspnea. See H&P. Wainwright
William J. Wainwright 0010
ALL: PCN -> Hives Diet - No added salt Activity Up to BR IV saline lock Meds: Lasix 80 mg IV now Humulin N 64 U SQ q.a.m. Humulin N 36 U SQ q.p.m. Humalog 12 U AC t.i.d. Hold if BS <120 Theo-Dur 200 mg p.o. b.i.d. Lasix 160 mg p.o. b.i.d. EC ASA 1 p.o. daily Imdur 60 p.o. q.h.s. Diazepam 10 mg p.o. q.h.s. Clorazepate 15 mg q.h.s. nitroglycerin 0.4 mg SL p.r.n. chest pain Pilocarpine 4% ophthalmic drops 1 drop O.D. q.i.d.
0011
O2 - keep sats above 88%
William J. Wainwright 0012
Albuterol nebs q.i.d. p.r.n. O2 William J. Wainwright
Form # _ _ _ _
Physician Orders and Progress Notes
© 2003. American Health Information Management Association. All rights reserved.
William J. Wainwright
Sundance Medical Center Painted Valley, USA Date/ Time
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502 Progress Notes
Orders
8/15
LAB: CBC, CMP, theo level, UA, TSH Lisinopril 20 mg p.o. q.a.m. EKG üdone ER CXR state, check if done ER P-8 in a.m. 8/15 Oximetry daily while on O2 Foley to gravity William J. Wainwright
8/15
May request Valium 10 mg q.h.s. p 3 hr p.m. x1 Accu-Chek q.i.d. EKG in a.m. Atrovent inhaler two puffs q.i.d.
Progress Note: 8/15 Social Services report from yesterday indicated pt currently uses no services. Will follow. W. Scarlett, MSW
William J. Wainwright 8/15
8/15
Change Atrovent inhaler to SVN’s q.i.d. v.o. Dr. Wainwright/rla William J. Wainwright @ 0945 < 101 131 171 221 301
Humalog q.i.d. S.S. 100 = 0 130 = 170 = 220 = 300 = 400 =
3 5 8 12 15
D/C H.s. Chlorazepate Inc Diazepam to 20 mg p.o. q.h.s. Ativan 2 mg p.o. t.i.d. p.r.n. anxiety Up walking William J. Wainwright
8/15 Breathing easier 110/60, P 80 Lungs clear, distant BS Heart - regular Abd soft Ext no edema Weight down 6 # - CHF - IDDM Increase activity Monitor O2 sats Dr. Wagner
William J. Wainwright 8/15
@ 1410 D/C Humalog 12 u a.c. t.i.d. T.O. Sally Mertz, RPO Sall;y J. Mertz, RPO
Form # _ _ _ _
Physician Orders and Progress Notes
© 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Painted Valley, USA Date/ Time
8/16
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502 Progress Notes
Orders
@ 0650 MOM 30 cc p.o. QP p.r.n. S.O. Dr. Wainwright, A. May, RN
William J. Wainwright 8/16
D/C Foley, D/C CCU, D/C IV
William J. Wainwright 8/16
Discharge Meds: Humulin N 64 U a.m. Humulin N 36 U p.m. Humalog sliding scale Accu-Chek
William J. Wainwright
Units < 100 = 0 101 130 = 3 131 170 = 5 171 220 = 8 221 300 = 12 301 400 = 15 > 400 = 18 Diazepam 20 mg p.o. q.h.s. albuterol & Atrovent SVN’s q.i.d. & p.r.n. Lasix 160 mg p.o. b.i.d. Theo-Dur 200 mg q.a.m., 300 mg q.h.s. Imdur 30 mg (1/2 tab) q.h.s. Pilocarpine 4% 1 drop O.D. q.i.d. nitroglycerin 0.4 mg SL p.r.n. chest pain O2 2 to 4 L/m N.C. Appt. my office - 2 wks
William J. Wainwright
Form # _ _ _ _
Physician Orders and Progress Notes
© 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Painted Valley, USA
Newman, Edward C. Dr. William J. Wainwright
Date/ Time
Nursing Progress Notes
Coronary care unit # 012502
8/14/xx 0805 Admission Admitted to CCU-3 per w/c from ER. Settles into bed with no c/o @ present. See admission sheet. HRM, RN Brenda Kellye, RN
Brenda Kellye, RN
0845
Foley catheter inserted. Tolerated well.
0900
Lisinopril 20 mg p.o. now given per order, Lasix 80 mg IV now given per order.
Brenda Kellye, RN 1000
Visiting with wife in room. No c/o at present.
Brenda Kellye, RN
1300
Dozing in bed quietly.
Brenda Kellye, RN
1500
Visiting in room with family. No c/o.
Brenda Kellye, RN
1900
Summary Appetite good. Denies pain. Resting quietly. Wife @ bedside. Rhythm unchanged.
2200
Summary Uneventful evening, denies pain. Does become SOB with activity, respirations easy @ rest. No c/o. Leslie Scorch, RN
Leslie Scorch, RN
8/15/xx 0115 SOB Resting awake in bed, had “Charley Horse” in leg. Better now, but dyspneic, resp 30/m et breathing rapidly, feels winded. LS dim throughout with left base crackles. Patient quite anxious. Robert K. Russo, RN
Robert K. Russo, RN
0115
SVN with albuterol 0.5 cc given.
0130
Breathing easier, increased air exchange throughout. Lungs fields with bibasilar crackles now. Feeling better, remains anxious. Robert K. Russo, RN
0150
Valium 10 mg p.o. repeated
0600
Awakened for assessment, had been sleeping. Becomes dyspneic on exertion with mild dyspnea with rest. LS remains dim throughout. Crackles lower 1/2 left and 1/4 left. Admits to feeling SOB, wants treatment. Robert K. Russo, RN
Robert K. Russo, RN
Nursing Progress Notes © 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Sundance Medical Center Painted Valley, USA
Dr. William J. Wainwright
Date/ Time
Nursing Progress Notes
Coronary care unit # 012502
8/15/xx
Robert K. Russo, RN
0615
SVN given with albuterol and atrovent
0625
Feeling better after treatment. Increased air exchange to lung fields though crackles remain, still has c/o feeling slightly SOB. Robert K. Russo, RN
0630
Lasix 160 mg p.o. given
0800
Resting well. Upon awakening slightly SOB. Sats 91-92% on 2 liters. Dim LS with faint bibasilar crackles. BS pos, Abd. neg. Ext. no edema. VS stable. Patient alert & oriented.
Robert K. Russo, RN
Brenda Kellye, RN 0830
Wife here. Patient eating. No c/o.
Brenda Kellye, RN
1000
Resting now. Resp. more at ease.
Brenda Kellye, RN
1030
Explained new S.S. insulin to patient and wife. No c/o, questions.
Brenda Kellye, RN Brenda Kellye, RN
1230
Stable. Resting. Resp. easy.
1300
Tried pt on 1L O2/NC, sats decrease to 87%. Increased to 2L/NC, sats 95%. Amb with 2LO2, 2 assist & Sat monitor on, 100 Fahrenheit. Sats to 92%. Back to room & up in chair. Did get slightly dyspneic with amb. More rested in chair. Sats back up 95% when sitting.
Anne Odinson, RN
1400
Back to bed with 2LO2. Sats 98%. No c/o. Restful. Lights out for a bit. Call light placed.
1450
Resting with easy, snoring like resp. Wife in room.
1600
Pt awake & talkative. Denies any discomfort. Resp easy at rest. Still has coarse rales in bases bilaterally. Color pink. Sats in mid 90’s on 2L. No pedal edema. C/o some weakness.
Anne Odinson, RN Anne Odinson, RN
Leslie Scorch, RN
Nursing Progress Notes © 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Sundance Medical Center Painted Valley, USA
Dr. William J. Wainwright
Date/ Time
Nursing Progress Notes
Coronary care unit # 012502
8/15/xx 1830 Appetite good. Assisted to ambulate 100 ft in hall with 2 assist & cont O2. Only slight staggered steps at times. Otherwise gait steady. To BR but unable to have BMO. Passed flatus. Had prune juice with supper. Leslie Scorch, RN 1930
VSS, resting quietly, denies physical c/o. Lungs diminished BS, O2 decreased 1/4 lit with some crackles, dec 1/4 lit SO2 96% @ 2L/NC. Re AP, inc pulses x 2, no c/o. Soft abd, Pos BS x 4, Foley patent with clear yellow urine. Leslie Scorch, RN
2030 2050
Bath done, cares done. Linen changed. Leslie Scorch, RN Accu ü Accuü 105, pt given Humalog 3 units. Pt h.s. snack.
2105
SVN
Leslie Scorch, RN
SVN with V.S. Albuterol & Atrovent given, tolerated well.
Leslie Scorch, RN
8/16/xx 0200 Sleeping in bed, breathing easily.
Robert K. Russo, RN
0115
SVN with albuterol 0.5 cc given.
Robert K. Russo, RN
0130
Breathing easy, good air exchange. Lungs fields with only minor crackles. No c/o at this time. Robert K. Russo, RN
0640
Feels better after treatment. Improving air flow in all lung fields. Foley catheter removed. IV discontinued. Robert K. Russo, RN
0700
Up to BR, voids well.
0800
Dr. Wainwright visits, discharge order written and discharge instructions given. Patient resting well. Blood sugar 130, vital signs stable. Ext. no edema. VS stable. Patient alert & oriented.
Robert K. Russo, RN
Brenda Kellye, RN 0830
Wife here. Patient eating. No c/o. Breakfast, eats well, somewhat short of breath while eating, otherwise no dyspnea, no c/o. Brenda Kellye, RN
Nursing Progress Notes © 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Painted Valley, USA Date/ Time
Nursing Progress Notes
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502
8/16/xx 1045 Discharge instructions discussed with patient and wife. They voice understanding. Will follow up with Dr. Wainwright at his office in two weeks. Brenda Kellye, RN 1115
Discharged per wheelchair, escorted to car.
Nursing Progress Notes © 2003. American Health Information Management Association. All rights reserved.
Brenda Kellye, RN
Sundance HealthCare Systems Patient Family Name
Painted Valley, USA
First Name
Newman,
Age
Edward C.
Room No.
78
CCU #2
Attending Physician
Date
Dr. William J. Wainwright Component
8/14/xx
Normal Date
Color Character Spec Gravity Leukocytes Nitrates
Yellow Clear 1.020 or less Negative Negative
PH Protein Urine Glucose Urine Ketones Urine
5-6 Negative Negative Negative
Urobilinogen Bilirubin Urine Occ Blood Urine WBC/HPF RBC/HPF Epitheial Casts/LPF Crystals Amorphorus Mucous Yeast Cells Bacteria
0 - 1 mg/dl Negative Negative 0-5 0-5
# 012502 Lab. No.
7734-2002
Second
Third
Fourth
Y / N
Y / N
Y / N
Yellow Clear 1.015 Negative Negative 5.2 Negative Negative Negative Negative Negative Negative 3-5 Few 15-20 Hylalin
Negative Negative
Sent for Culture: 24 Hour Urine
First 08/14/xx
Hosp. No.
Y / N 0 - 30
for Microalbumin
Form L-9001 (5/01) pa
URINALYSIS
© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502
Diagnosis: CHF, COPD Allergies: Penicillin Medication and Date of Order
Hosp Day Hosp Day Hosp Day Hosp Day 8/15 # 8/16#3 #4
Route 8/14 #1
1.
Lisinopril 40 mg p.o. q.a.m.
08
SMB
SGA
2.
Theo-Dur 200 mg p.o. b.i.d.
08
ams
SMB
21
nmr
kl
08
ams 1200
SMB
KJN
17
pvm
rlw
KJN KJN
3. 4.
Lasix 160 mg p.o. b.i.d.
5. 6.
EC ASA 1 p.o. daily
08
ams
SMB
7.
Imdur 60 p.o. q.h.s.
21
nh
kl
8.
Diazepam 10 mg p.o. q.h.s.
21
nh
9.
Pilocarpine 4% 1 gtt OD q.i.d.
08
/
SMB
10.
12
pvm
SMB
11.
16
mds
swb
12.
21
taf
ko
see D’s below
13.
Clorazepate 15 mg q.h.s.
21
wlk
dcd 8/15
14.
Diazepam 20 mg p.o. q.h.s.
21
/
ko
15. 16. 17. 18. 19. 20.
MEDICATION PROFILE
© 2003. American Health Information Management Association. All rights reserved.
KJN
KJN
Sundance HealthCare Systems Patient Family Name
Newman,
Painted Valley, USA
First Name
Age
Room No.
Edward C.
78
CCU #2
Attending Physician
Date
Dr. William J. Wainwright Component
8/14/xx
Normal Date
First 08/14/xx
Chemistry 10 Sodium Potassium Chloride CO2 Glucose BUN Creatinine Total Bili Albumin Calcium
135 3.5 100 23 80 12 0.6 0.0 3.5 8.2
-
145 5.3 110 29 116 20 1.3 1.3 5.0 10.1
143 4.4 100 35 238 27 1.5 0.7 3.9 9.8
ALP AST ALT Total Protein
56 0 14 6.0
-
112 27 26 8.0
58 21 18 6.6
Theo TSH
10.0 - 20.0 0.4 - 6.2
8.2 1.9
Lipid Profile Total Choles HDL LDL Triglycerides
100 40 66 50
-
H H H H
Second 08/15/xx
143 3.8 100 36 91 35 1.6
9.4
L
200 80 130 150
HG A1C
4.0
- 6.0
PSA
0.0
- 4.0
Form L-9003 (5/01) pa
CHEMISTRY
© 2003. American Health Information Management Association. All rights reserved.
H H H
Third
Hosp. No.
# 012502 Lab. No.
7734-2002 Fourth
Sundance HealthCare Systems Patient Family Name
Newman,
Painted Valley, USA
First Name
Age
Room No.
Edward C.
78
CCU #2
Attending Physician
Date
Dr. William J. Wainwright Component
8/14/xx
Normal Date
Hematology WBC (x 103) RBC (x 103) Hgb (g/dl) HCt (%) MCV (x 103) MCH (x 103) MCHC (%) PLT (x 103) Differential Band Seg Lymph Mono Eosin Baso NRBC Atyp Lymph Meta Myelo Pros Blast
M/F
4.3 - 11.0
M
4.6 - 6.2
F
4.2 - 5.4
M F M F
12 12 40 36
First 08/14/xx
10.4 4.25 13.6
M F M/F M/F
80 - 94
95.7
M/F
150 - 375
H
18 16 54 47
0 46 13 4 0 2
-
Second
40.6
82 - 100
26 - 33 31 - 36
-
Form L-9003 (5/01) pa
6% 82% 37% 12% 5% 2%
32.0 33.4
76 15 4 3 3
H
HEMATOLOGY
© 2003. American Health Information Management Association. All rights reserved.
Third
Hosp. No.
# 012502 Lab. No.
7734-2002 Fourth
Sundance HealthCare Systems Painted Valley, USA
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502
CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: This patient is a 78-year-old resident of Podunk Center. He has a long-standing history of severe COPD, insulin-dependent diabetes mellitus and ASHD and status post MI’s. According to the patient he has been severely short of breath over the past several months. Apparently this has increased over the past two days and yesterday it severely limited his ability to get up and walk around. During the night last night, at approximately 5:00 a.m., he had a severe episode of shortness of breath. He received two nebulizer treatments and his wife turned his home oxygen up wide open. Despite this, however, he remained severely short of breath. His wife then called 911 and he was brought to the ER via ambulance. The patient denies substernal chest pain. He states that he has gained approximately five pounds over the past couple of weeks. He also admits to swelling of both ankles at the end of the day. PAST MEDICAL HISTORY: Several episodes of COPD in the past. He has also been admitted with MI’s at age 66 and again in September, three years ago. He has had congestive heart failure and long-standing insulin-dependent diabetes mellitus. He has glaucoma and chronic blindness in his right eye. He has a history of long-standing noncardiac chest pain. He has also had peptic ulcer disease. PAST SURGICAL HISTORY: He is status post T&A, hemorrhoidectomy x 2, colonoscopy with polypectomy in six years ago which revealed a tubular adenoma, right inguinal herniorrhaphy four years ago, another colonoscopy repeated three years ago. He had a TURP in 1981 for benign prostatic hypertrophy. MEDICATIONS: Humulin N 64 units in the morning and 64 units in the evening. Humalog sliding scale t.i.d., usually taking 14 to 16 units at mealtimes. He also takes Theo-Dur 200 mg b.i.d., Lasix 160 mg a.m. and 80 mg at noon q.d. Ecotrin 325 mg q.d. Pilocarpine 4% ophthalmic drops 1 drop right eye q.i.d., Imdur 60 mg q.h.s., Diazepam 10 mg q.h.s., Clorazepate 15 mg q.h.s., nitroglycerin 0.4 mg sublingual p.r.n. chest pain, albuterol and Atrovent nebulizer q.i.d. and p.r.n. He is on home O2 routinely at 2 liters per minute per nasal cannula. ALLERGIES: Penicillin causes a rash. HABITS: 150 pack year history of cigarette smoking. He is currently a nonsmoker, does not drink alcohol. FAMILY HISTORY: The patient is married and is a retired teacher. He lives in Podunk Center with his wife who also has had some health problems, including atrial fibrillation. They have three children in the area. REVIEW OF SYSTEMS: General: No seizures or syncope. He has had the weight gain as mentioned above. HEENT: No recent change in hearing or vision. He does have the glaucoma as mentioned above. Dr. Signature Form 9427 (8/00) mr
HISTORY & PHYSICAL
© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
Newman, Edward C. Dr. William J. Wainwright Coronary care unit # 012502
Respiratory: As above. Cardiac: See HPI. GI: No nausea, vomiting, diarrhea, constipation, hematochezia or melena. GU: No burning, hematuria or recent UTI. He states that he does have nocturia one to two times per night. Musculoskeletal: Negative. Neurologic: He has been depressed over his breathing difficulties. PHYSICAL EXAMINATION: General: This is a well-developed, well-nourished 78-year-old white male, sitting up on the examining table with oxygen running. He appears in no acute distress at this time. Vital Signs: Blood pressure 144/72, pulse 108, respirations 38, temperature 96.4 degrees Fahrenheit. Weight 190 pounds. Skin: Anicteric, warm and dry. Face is slightly flushed at this time. Heent: Shows clear TMs. Pupils equal, round and reactive to light on the left. There is evidence of corneal dystrophy on the right. Oropharynx is clear. Neck: Supple, no cervical lymphadenopathy. Chest: Lungs have slight crackles in the right mid-lung field and base, clear on the left. Heart: Regular rate and rhythm without murmur or gallop. Abdomen: Normal bowel sounds, soft and nontender. No masses, hernias or organomegaly noted. Genitalia: External genitalia is normal. Extremities: Warm and well perfused. There is trace edema bilaterally. Pedal pulses are palpable. Neurologic: Motor and strength are 5/5 bilaterally. DTRs are symmetrical. Psych: Affect is more flat than typically seen. Recent and remote memory are good. Judgement and insight are intact. Does seem to be slightly depressed. LABS: Chest x-ray shows cardiomegaly and evidence of vascular redistribution consistent with CHF. EKG shows normal sinus rhythm at a rate of 94 beats per minute. There is evidence of an old anterior MI and an old inferior MI. No acute appearing ST-T wave changes. Sodium is 143, potassium 4.4, BUN 27, creatinine 1.5, glucose 238. CBC shows white count 10,400 with a normal differential, hemoglobin 13.6, hematocrit 37.9. ASSESSMENT: 1. A 78-year-old white male with cor pulmonale and congestive heart failure secondary to his severe chronic obstructive pulmonary disease and coronary artery disease. 2. Arteriosclerotic heart disease with history of previous myocardial infarctions and congestive heart failure. 3. Chronic glaucoma with right eye blindness. 4. Chronic insomnia. 5. Insulin-dependent diabetes mellitus. 6. Benign prostatic hypertrophy, status post transurethral resection of prostate. PLAN: The patient will be admitted to the CCU. Monitor his O2 saturations, provide oxygen as necessary and diurese him. Dr. William J. Wainwright Signature D&T: 8/14/xx Form 9427 (8/00) mr
HISTORY & PHYSICAL
© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
Date Time
Newman, Edward C. Dr. Dr. William J. Wainwright Coronary care unit # 012502
08/14 _____________
08/15 _____________
08/16 _____________
_____________
3 6 9 12 15 18 21 24
3 6 9 12 15 18 21 24
3 6 9 12 15 18 21 24
3 6 9 12 15 18 21 24
105 ................................................................................................................................................... 104 ................................................................................................................................................... 103 ................................................................................................................................................... 102 ................................................................................................................................................... 101 ................................................................................................................................................... 100 ................................................................................................................................................... 99
...................................................................................................................................................
98
...................................................................................................................................................
97
...................................................................................................................................................
96
...................................................................................................................................................
95
...................................................................................................................................................
Pulse
93
102
89
88
86
76
Resp.
38
20
21
24
20
18
B/P
143 72 144 62 136 74 ___/___| 140 78 ___/___| 110 60 122 76 122 78 ___/___| ___/___ ___/___| ___/___| ___/___ ___/___| ___/___| ___/___ ___/______/___| ___/___| ___/___| ___/___ ___/___| ___/___| ___/______/___| ___/___| ___/___ ___/___| ___/___| ___/___
In ______| ______| ______ Out ______| ______| ______
Weight:
195.7 194.9 ______ | _______
ADA ______ ADA Diet ______| ______| Good ______ Fair ______|
Appetite ______|
______| ______| ______ ______| ______| ______
193.3 192.6 ______ | _______
ADA ______| ADA ADA ______| ______ Fair Good Good ______| ______| ______
______| ______| ______ ______| ______| ______
190.4 | _______ ______
ADA ______| ______ ______| Fair ______| ______| ______
GRAPHIC SHEET © 2003. American Health Information Management Association. All rights reserved.
______| ______| ______ ______| ______| ______
______ | _______
______| ______| ______ ______| ______| ______
Sundance HealthCare Systems Painted Valley, USA Street Address
Patient's Name
Newman, Edward C. Birth Date
Age
04/01/xx
Phone Number
Devils Lake
Marital Status
M
# 012502
City
78
Sex
Hospital Number
2720 Mountain View
701
State
Married
Zip
N.D.
Soc. Sec. #
County
58301
Ramsey
CCU #2 Race
Religion
504-59-3132
Methodist
W Ethnicity
Patient's Occupation
Teacher (Retired) Notify In Emergency
801-7734
Room
Non-Hispanic Name
Relationship
Mildred
Responsible for Account
Wife
Address
Self
Phone No.
2720 Mountain View, Devils Lake Date Admitted
Time
8/14/xx
0645
701 AM PM
801-7734
Date Discharged
08/16/xx
Time
1111
AM PM
Name & Address of Any Institution From Which Discharged in Last 60 Days
Date of Last Admission
2/29/xx
N/A Consultant
Admitting Physician
Dr. William J. Wainwright Aitemding Physician
Dr. William J. Wainwright ICD-9-CM CODES
Admitting Diagnosis (Within 24 Hours)
Cor pulmonale and congestive heart failure secondary to severe chronic obstructive pulmonary disease and coronary artery disease. Principal Diagnosis
1.
Congestive heart failure complicating severe chronic obstructive pulmonary disease.
Secondary Diagnoses
2. 3. 4.
Arteriosclerotic heart disease with history of myocardial infarctions. Insulin-dependent diabetes mellitus. Glaucoma.
Complications
Operative Procedures (Date & Title)
ü
Discharged Alive ____
Died ____
Autopsy Yes ____
No ____
William J. Wainwright
Physician Signature
ADMISSION SUMMARY SHEET This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental. © 2003. American Health Information Management Association. All rights reserved.
CONDITIONS OF ADMISSION 1. CONSENT TO HOSPITAL CARE I am presenting myself for admission to St. Jude’s Medical Center. I voluntarily consent to the rendering of medical care which is determined to be necessary or beneficial in the professional judgement of my physician. This includes routine diagnostic procedures and medical treatment by authorized agents and employees of the Hospital, and by its medical staff, or their designees. I acknowledge that no guarantees have been made to me as to the effect of such examination or treatment on my condition. 2. AUTHORIZATION TO RELEASE INFORMATION I authorize St. Jude’s Medical Center to release such information from my medical record as may be necessary for the completion of the hospital’s or my physician’s claims for reimbursement to my insurance company or agency. I UNDERSTAND THAT DISCLOSURE MAY INCLUDE DIAGNOSES AND OPERATIONS OR PROCEDURES PERFORMED AND THAT, AT THE REQUEST OF MY INSURANCE COMPANY OR AGENCY, MY COMPLETE MEDICAL RECORD MAY BE SUBJECT TO REVIEW. IN ADDITION, I UNDERSTAND THAT COPIES OF MY RECORD MAY BE OBTAINED BY MY INSURANCE COMPANY OR AGENCY. 3. ASSIGNMENT OF BENEFITS In consideration of the services received or to be received for this admission to St. Jude’s Medical Center, I assign all insurance benefits due me. I further warrant that the hospital shall be entitled to the full amount of its charges. Any credit balance resulting for any reason will be applied to other existing accounts. This also assigns benefits to Anesthesia Consultants, PC. I hereby agree to pay any and all hospital charges that exceed or that are not covered by my hospitalization insurance coverage. This assignment shall be irrevocable. 4. VALUABLES DISCLAIMER I understand that St. Jude’s Medical Center maintains a safe for the safekeeping of money and valuables. I, also, understand that I assume full responsibility for any and all of my valuables, money, clothing, dentures, and other personal items while a patient in the hospital unless deposited with the Hospital for safekeeping. Valuables Deposited with the Hospital
ü
YES
NO
5. REQUEST FOR FACILITY ACCOMMODATIONS I agree to pay to the Hospital any difference between the semi-private rate provided by my hospitalization insurance and the Hospital charges for a private accommodation. I understand that private accommodations are more expensive than the room rate payable by my hospitalization insurance and that it is my responsibility to pay the difference. I request a Private Room
YES
ü
NO
This document has been fully explained to me, and I certify that I understand its contents and agree to it freely.
August 14, xx DATE
0645 TIME
AM PM
Edward
C.
Newman
Patient or authorized person
Marilyn Flemming Witness
Relationship Guarantor/Insured Certificate Holder
Signature is not that of the patient because: ( ) patient is a minor ( ) other reason (specify):
Sundance HealthCare Systems Painted Valley, USA Patient's Name
Street Address
Hospital Number Phone Number
Birth Date
Age
City
Sex
Marital Status
State
Soc. Sec. #
Zip
County
Race
Religion
Ethnicity
Patient's Occupation Notify In Emergency
Name
Relationship
Address Date Admitted
Room
Responsible for Account
Phone No. Time
AM PM
Date Discharged
Time
AM PM
Date of Last Admission
Name & Address of Any Institution From Which Discharged in Last 60 Days
Admitting Physician
Consultant
Aitemding Physician
ICD-9-CM CODES
Admitting Diagnosis (Within 24 Hours)
Principal Diagnosis
Secondary Diagnoses
Complications
Operative Procedures (Date & Title)
Discharged Alive ____
Died ____
Autopsy Yes ____
No ____ Physician Signature
ADMISSION SUMMARY SHEET This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental. © 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA Patient's Name:
Last Name
EMERGENCY ROOM / OUTPATIENT RECORD Account Number:
First Name
Newman,
Edward
Address:
C.
State
Devils Lake
Employer: Address: Responsible Party: Address:
Alfred E. Newman Devils Lake, ND
Name of Insurance Company Address of Insurance Co.
Home Phone
58301
Age
08/14
Sex
78
a.m. p.m.
Admission Date
701 801-7734 Zip
N.D.
Retired Tokyo, ND
Notified:
Middle Initial
Date of Birth
Civil Status
M 04/01 Teacher Occupation:
Medicare Hooterville, ND
Policy No.
# 012502 Religion
Methodist 504-59-3132 Soc. Sec. #
S M W D Sep
Phone No: Occupation: Phone No:
Med.Rec. Number
Notify Press
Yes
No
Teacher 801-7734
Family Doctor: Dr. Wainwright Notified Yes No
AP 504-39-3132
Brought In By: ___ Police ___
Relative
Mildred
Relationiship:
Wife
By Whom
Police
No
Coroner
No
Time
Agathie Chrsty
0645
Relative
___ xx ___
Self Fire
___
Other
Race: Ethnicity:
a.m./p.m.
BRIEF HISTORY: (If accident, state where, when & how injured; if illness describe) :
78-year-old male to ER per ambulance. Awoke at 0600 with acute respiratory distress. Hx COPD. Did home nebulizers without relief. Ambulance called for transport. Second neb started et finished en route. Accu ü done also “200”. Currently mildly dyspneic, respirations 38, lungs slightly et moderate diminished. SAO2 98% on 2 liter p.m. NC. ??? Rhythm NS without ectopics. 0725 Saline lock 22 g 28 mm Jelco started L hand - Lasix 80 mg IV push. Lock flushed per protocol NUB. 0730 Dr. Wainwright in to examine patient. 0740 Admit Coronary care unit . 0810 Patient to floor in W/C per RN
Allergies: Penicillin
Patient Medications: See attached sheet. PHYSICIAN'S REPORT: History & Physical Findings:
Condition on Admission: Good Poor
____ ____
Coma ____ Vital Signs:
Fair Shock
____ xx ____
Hemorrhage
____
home O2. O2 sat on 2LNC 96%
Pulse increased,
Adm H:
CHF
RR 28 pm
ASHD
Heart: WNL.
Resp. B.P.
96.4 ____ 108 ____ 48 ____ 143 72 ____/____
Normal
Other
System Inventory:
o o
o o
Mental/Emotional Status:
ü o
o
Skin
ü o
Respiratory
o
Cardiovascular.
Referred to Dr.
o
Musculoskeletal:
Instructions to Patient:
o
Gastrointestinal
o
Genitourinary
o
Neurological
Temp. Pulse
o
ü o ü o ü o ü o ü o
ü o o Form # _ _ _ _
EENT
Height: 72" Weight: 190 SAO2 96%
Increasing shortness of breath 6:00 a.m. No chest pain. No cough. Has been on
Diagnosis:
Lungs: Expiratory wheezes bilaterally. Lower extremity edema 1+.
Treatment (including medications):
Disposition of Case:
Admitted to CCU, LAB: CXR, EKG, CBC, PO2 (Theo Old charts
per Dr. Wainright / Ries RN)
Edward C. Newman
A: Acute exacerbation of asthma / LVF. Lasix 20 mg IV Date: P: Admit to CCU.
8/14/xx
Patient's Signature
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Date
6:45 Time
William J. Wainwright Attending Physician
PATIENT:
DATE:
A.M. P.M.
DATE:
1. I, (or
)
acting for
)
knowing that I, (or ) am (is) suffering from a condition requiring emergency or out patient care do hereby voluntarily consent to such care encompassing diagnostic procedures and medical treatment by Dr. his assistants or his designees as is necessary in his judgement. 2.
I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatments or examination in the hospital.
3.
This form has been fully explained to me and I certify that I understand its contents.
Witness
Signature of Patient
(If patient is unable to consent or is a minor, complete the following): Patient (is a minor years of age) is unable to consent because
Witness
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Closest Relative or Legal Guardian
Sundance HealthCare Systems Painted Valley, USA Patient's Name:
Last Name
EMERGENCY ROOM / OUTPATIENT RECORD Account Number:
First Name
Address:
Middle Initial
State
Zip
Home Phone
Admission Date
Age
Date of Birth
Sex
a.m. p.m.
Med.Rec. Number
Civil Status
Religion
S M W D Sep
Employer: Address:
Occupation: Phone No:
Soc. Sec. # Notify Press
Responsible Party: Address:
Occupation: Phone No:
Family Doctor: Notified
Policy No.
Brought In By: ___ Police
Name of Insurance Company Address of Insurance Co. Notified:
___
Relative
Relationiship:
By Whom
Police
Coroner
Time
Relative
Yes
No
Yes
No
___ ___
Self Fire
___
Other
Race: Ethnicity:
a.m./p.m.
BRIEF HISTORY: (If accident, state where, when & how injured; if illness describe) :
PHYSICIAN'S REPORT: History & Physical Findings:
Condition on Admission: Good Poor
____ ____
Coma ____ Vital Signs:
Fair Shock
____ ____
Hemorrhage
____
Temp. Pulse
____ ____
Resp. B.P.
____ ____/____
Normal
Other
System Inventory:
o o
o o
Mental/Emotional Status:
o
o
Skin
o
o
Respiratory
o
o
Cardiovascular.
Referred to Dr.
o
o
Musculoskeletal:
Instructions to Patient:
o
o
Gastrointestinal
o
o
Genitourinary
o
o
Neurological
o o Form # _ _ _ _
Diagnosis:
Treatment (including medications):
Disposition of Case:
Date:
EENT Patient's Signature
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Date
Time
Attending Physician
Sundance HealthCare Systems Painted Valley, USA
NEWMAN, Edward C.
# 012502
Age 78
CCU
Dr. D. J. Wagner
8-14-xx
a.m.
MECHANISM:
Normal sinus rhythm
RATE:
94 beats per minute
AXIS
Left axis deviation. P-R-T axes 68 - 55 116
PW:
Are broadened. P-R interval 162 ms
COMPLEXES:
Normal voltage. Left ventricular hypertrophy with QRS widening. Left atrial enlargement. QT/Qtc 317/398 ms. QRS interval is 118 ms.
TW:
Nonspecific ST and T-wave abnormality.
COMMENT:
Abnormal EKG, possible lateral ischemia. Old anterior MI. No change from previous EKG.
DJW/bg St. Luke’s D&T: 8-14-xx
Donald J. Wagner Cardiologist Signature Form 4101
(10/01) mr
ELECTRCARDIOGRAM
© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
NEWMAN, Edward C. Dr. William J. Wainwright Coronary care unit # 012502
DISCHARGE SUMMARY: This patient is a 78-year-old gentleman from Podunk Center. He was admitted because of increasing problems associated with his chronic congestive heart failure, COPD, diabetes and ASHD. The patient was experiencing increasing dyspnea associated with the CHF. He was given an IV and increased dose of Lasix. Following this the patient diuresed approximately five pounds during his hospitalization. Both his O2 saturations and breathing steadily improved. Two days after admission he was feeling much better. He had been up walking and was having no chest pain. He is being discharged in improved condition. DISCHARGE MEDICATIONS: Diazepam 20 mg p.o. q.h.s., albuterol and Atrovent nebulizers q.i.d. and p.r.n., Lasix 160 mg p.o. b.i.d.; TheoDur 200 mg q.a.m., 300 mg q.h.s.; Imdur 30 mg (1/2 tab) q.h.s., Pilocarpine 4% 1 drop O.D. q.i.d., nitroglycerin 0.4 mg sublingual p.r.n. chest pain, oxygen 2 to 4 liters per minute per nasal cannula. For his diabetes he will be on Humulin N 64 U a.m., Humulin N 36 U p.m. and Humalog sliding scale as follows: Accu-Chek less than 100 = 0, Accu-Chek 101 - 130 = 3, Accu-Chek 131 - 170 = 5, Accu-Chek 171 - 220 = 8, Accu-Chek 221 - 300 = 12, Accu-Chek 301 - 400 = 15, Accu-Chek more than 400 = 18. FOLLOW-UP: Mr. Newman has an appointment to see me in the office in approximately two weeks for recheck. He should call or come in sooner if he has any questions or problems prior to that appointment. He is to check his weights on a daily basis at home and if he gains more than two pounds from his discharge weight he is to call me at once or come into the ER or walk-in clinic. FINAL DIAGNOSIS: 1. Congestive heart failure complicating severe chronic obstructive pulmonary disease. 2. Arteriosclerotic heart disease with history of myocardial infarctions. 3. Insulin-dependent diabetes mellitus. 4. Glaucoma. PROCEDURES: None. COMPLICATIONS: None.
William J. Wainwright
DJW/sgs D&T: 8/16/xx Form 9055 (3/98) him
DISCHARGE SUMMARY
© 2003. American Health Information Management Association. All rights reserved.
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