Microsoft Word – IPCase001.doc Global Care Medical Center 100 Main…

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 answered 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
••X••X•• •

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:

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