Download INPATIENT FACE SHEET

Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
Hospital No. 999
WEST, KEITH
417 RUSH ROAD
ALMOND, NY 14804
M
W
05/23/YYYY
8 mo
S
IPCase010
N/A
N/A
!
02-09-YYYY
15:55
02-11-YYYY 1300
02 DAYS
"
WEST, KEN
417 RUSH ROAD
ALMOND, NY 14804
#
WEST, KELLY
417 RUSH ROAD
ALMOND, NY 14804
"
(607)000-8107
(607)000-8107
Father
#
!
(607)000-8107
Mother
$
! %
Fred Moore, MD
N/A
N/A
John Black, MD
BRONCHIOLITIS / CROUP
&
!
Blue Cross of WNY
331
&
76894567-900
N/A
!
N/A
Bronchiolitis with fever
Croup tent with nebulizer
&
$ :
Bed rest
Light
'
Regular
Low Cholesterol
Follow-Up:
&
Call for appointment
Usual
Unlimited
Low Salt
Office appointment on
ADA
Other:
Soft
Recheck in one week.
:
'
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 02/09/YYYY 04:20:44 PM EST)
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
I, Keith West
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.
Signature of Patient
Reviewed and Approved: Kelly West
ATP-B-S:02:1001261385: Kelly West
(Signed: 02/09/YYYY 04:32:05 PM EST)
Signature of Parent/Legal Guardian for Minor
Relationship to Minor
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 02/09/YYYY 04:32:05 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.
Signature of Patient
Reviewed and Approved: Kelly West
ATP-B-S:02:1001261385: Kelly West
(Signed: 02/09/YYYY 04:36:17 PM EST)
Signature of Parent/Legal Guardian for Minor
Relationship to Minor
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 02/09/YYYY 04:36:24 PM EST
WITNESS: Global Care Medical Center Staff Member
GLOBAL CARE MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
Your answers to the following questions will assist your Physician and the Hospital to respect your wishes regarding your medical
care. This information will become a part of your medical record.
YES
NO
1.
Have you been provided with a copy of the information called
“Patient Rights Regarding Health Care Decision?”
2.
Have you prepared a “Living Will?” If yes, please provide the
Hospital with a copy for your medical record.
X
3.
Have you prepared a Durable Power of Attorney for Health Care?
If yes, please provide the Hospital with a copy for your medical
record.
X
4.
Have you provided this facility with an Advance Directive on a
prior admission and is it still in effect? If yes, Admitting Office to
contact Medical Records to obtain a copy for the medical record.
X
5.
Do you desire to execute a Living Will/Durable Power of
Attorney? If yes, refer to in order:
a. Physician
b. Social Service
c. Volunteer Service
X
PATIENT’S INITIALS
X
HOSPITAL STAFF DIRECTIONS: Check when each step is completed.
1.
Verify the above questions where answered and actions taken where required.
2.
If the “Patient Rights” information was provided to someone other than the patient, state reason:
Name of Individual Receiving Information
Relationship to Patient
3.
If information was provided in a language other than English, specify language and method.
4.
Verify patient was advised on how to obtain additional information on Advance Directives.
5.
Verify the Patient/Family Member/Legal Representative was asked to provide the Hospital with a copy of the
Advanced Directive which will be retained in the medical record.
File this form in the medical record, and give a copy to the patient.
Name of Patient Name of Individual giving information if different from Patient
Reviewed and Approved: Kelly West
ATP-B-S:02:1001261385: Kelly West
(Signed: 02/09/YYYY 04:35:05 PM EST)
Signature of Parent/Legal Guardian for Minor
Date
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 02/09/YYYY 04:35:47 PM EST
Signature of Hospital Representative
GLOBAL CARE MEDICAL CENTER
Date
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
ADMISSION DATE:02/09/YYYY
DISCHARGE DATE: 02/11/YYYY
ADMISSION DIAGNOSIS: Bronchiolitis with hyperpyrexia; history of premature delivery with
one hospitalization for lung immaturity at time of birth.
DISCHARGE DIAGNOSIS: Bronchiolitis with fever and poor fluid intake.
SUMMARY: This is an 8-month-old white male seen by Dr. White at the Lofty Pines Health
Center for a viral-type syndrome. The mother states that the baby had a temperature over
the weekend, going up to 104 and 103 the night prior to admission. The baby has
progressively gotten more worked up, more short of breath and has had respiratory disease.
The patient was hospitalized for his respiratory distress and lower respiratory disease.
Positive physical exam on admission included both lung fields filled with rhonchi and
occasional rales. There were no signs of consolidation. The patient was put in a croup
tent during his hospital stay and was placed on Ampicillin four times a day for his twoday course. He tolerated the croup tent well and the antibiotics. His lungs progressively
cleared, and the patient was discharged on 02-11-YYYY. He was discharged on the
instructions to force fluids, saline nose drops and bulb suction as needed, Amoxicillin
125 milligrams three times a day, and to return to the clinic in one week to see Dr.
Swisher.
Lab data – white count was 10.7, hemoglobin was 12.2, hematocrit was 37.7, 13 segmented
cells, 77 lymphocytes, 10 monocytes. Chest x-ray was within normal limits.
DD: 02/11/YYYY
Reviewed and Approved: Fred Moore MD
ATP-B-S:02:1001261385: Fred Moore MD
(Signed: 02/11/YYYY 04:14:44 PM EST)
Physician Authentication
DT: 02/20/YYYY
GLOBAL CARE MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
CHIEF COMPLAINT: Difficulty breathing and hyperpyrexia
HISTORY OF PRESENT ILLNESS: This is an 8-month-old white male seen by Dr. White at the
Lofty Pines Health Center for a viral-type syndrome. The mother states that the baby had
a temperature over the weekend with it being 104 on Saturday night and 103 last night.
The baby has progressively gotten more worked up, more short of breath and has had more
problems with congestion. The baby was admitted for observation and evaluation of his
upper respiratory and lower respiratory disease. This is the first hospitalization for
this child.
PAST MEDICAL HISTORY: This baby only has one other hospitalization besides that of birth
and that was for admission to the hospital for respiratory distress syndrome and was
taken care of by Dr. Smith in the neonatal intensive care unit. He only stayed less than
a week and did quite well and there was no need for follow up. The mother states that the
patient was born three weeks early and the doctors felt that this was secondary to her
having a kidney stone. The child had a normal, spontaneous, vaginal birth. He was 19
inches at birth and weighed 6 pounds 15 ounces.
FAMILY HISTORY: There is a family history of diabetes, paternal great grandmother; heart
disease, grandfather. One brother has congenital heart disease, and an uncle has
congenital heart disease. There are 2 maternal aunts who died of myocardial infarction.
There is no tuberculosis, hypertension, or cancer in the family. There also is a family
history of paternal grandfather with allergies and desensitizations. Mother and father do
not have allergies.
SOCIAL HISTORY: This is an only child.
REVIEW OF SYSTEMS: Growth and development is within normal limits. Patient is a good
eater, nonfussy. Still takes occasional Prosobee but is not on a strict formula diet at
this time.
GENERAL: This is an 8-month-old looking his stated age with respiratory problems with a
rapid rate and rather annoyed with a stuffed-up nose.
TEMPERATURE: 101.3
PULSE: 158
RESPIRATIONS: 62
DD: 02/09/YYYY
DT: 02/10/YYYY
Continued on next page
Physician Authentication
GLOBAL CARE MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
Page 2 continued
EENT: Extraocular movements are full. Pupils are equal, round, and reactive to light and
accommodation – red reflexes within normal limits. Nose – stuffed up with clear
rhinorrhea. Mouth – within normal limits.
CHEST: Both lung fields are filled with rhonchi and occasional rales. There were no signs
of consolidation.
HEART: Regular rhythm. Without murmur, rub, or gallop that I can detect, but the patient
indeed had a tachycardia at the time of examination.
ABDOMEN: Within normal limits.
GENITALIA: Circumcised male with testes descended. Good femoral pulses bilaterally. No hip
clicks.
RECTUM: Anus patent.
EXTREMITIES: Within normal limits.
LAB DATA: Complete Blood Count revealed: White count was 10.7, hemoglobin was 12.2,
hematocrit was 37.7, 13 segmented cells, 77 lymphocytes, 10 monocytes. Urinalysis was
within normal limits except for trace blood on dipstick; doubt whether that is
significant. Chest x-ray was within normal limits.
IMPRESSION: 1. Bronchiolitis with hyperpyrexia. 2. History of premature delivery with one
hospitalization for lung immaturity at time of birth.
Patient will need forced fluids and close observation.
DD: 02/09/YYYY
Reviewed and Approved: Fred Moore MD
ATP-B-S:02:1001261385: Fred Moore MD
(Signed: 02/09/YYYY 04:14:44 PM EST)
DT: 02/10/YYYY
Physician Authentication
GLOBAL CARE MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
Date
Time
02/09/YYYY
1600
Physician’s signature required for each order. (Please skip one line between dates.)
Chief complaint: Fever and coughing.
Diagnosis: Bronchiolitis with fever
Plan of Treatment: Croup tent. Fluids
DISCHARGE PLAN: Home. No services needed
Reviewed and Approved: Fred Moore MD
ATP-B-S:02:1001261385: Fred Moore MD
(Signed: 02/09/YYYY 04:10:55 PM EST)
02/10/YYYY
0800
Bronchiolitis / Respiratory distress
Lungs – Rhonchi throughout
- much looser
Temperature lower
Breathing easier – Respiratory rate 30 a minute\
Reviewed and Approved: Fred Moore MD
ATP-B-S:02:1001261385: Fred Moore MD
(Signed: 02/10/YYYY 08:04:07 AM EST)
02/11/YYYY
0800
Bronchiolitis / Respiratory distress
Lungs – Rhonchi throughout
- much looser
Temperature lower
Intake good.
Reviewed and Approved: Fred Moore MD
ATP-B-S:02:1001261385: Fred Moore MD
(Signed: 02/11/YYYY 08:10:32 AM EST)
GLOBAL MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
Date
Time
02/09/YYYY 1650
Physician’s signature required for each order. (Please skip one line between dates.)
Admit to service Dr. Black
Admitting diagnosis: Bronchiolitis
Vitals every shift
Coup tent with oxygen continuous and while sleeping
Daily weight
Complete Blood Count
Urinalysis
Chest x-ray to rule out pneumonia
Milk-free diet. Encourage fluids, Gatorade.
Sudafed 2.5 centimeters 4 times a day as needed for
congestion
Amoxicillin 125/5 centimeters 4 times a day
Nasopharynx and throat cultures
Please call Dr. Moore when blood work and x-ray are
done.
Reviewed and Approved: Mary Stanley RN
ATP-B-S:02:1001261385: Mary Stanley RN
(Signed: 02/09/YYYY 04:54:07 PM EST)
02/09/YYYY 1700
1 grain aspirin or 1 grain Tylenol by mouth or
suppository every 4 hours as needed.
Reviewed and Approved: Mary Stanley RN
ATP-B-S:02:1001261385: Mary Stanley RN
(Signed: 02/09/YYYY 04:54:07 PM EST)
02/09/YYYY 2315
Please do nose irrigation with normal saline 2-3 drops
in each nostril – then suction with bulb syringe and
needed.
Reviewed and Approved: Mary Stanley RN
ATP-B-S:02:1001261385: Mary Stanley RN
(Signed: 02/09/YYYY 11:54:07 PM EST)
GLOBAL CARE MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
Date
Time
02/11/YYYY 1300
Physician’s signature required for each order. (Please skip one line between dates.)
Discharge.
Force fluids
Saline nose drops and suction
Amoxicillin 125/5 centimeters three times a day
Return to clinic one week
Summary dictated.
Reviewed and Approved: Fred Moore MD
ATP-B-S:02:1001261385: Fred Moore MD
(Signed: 02/11/YYYY 01:05:52 PM EST)
GLOBAL CARE MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
02/09/YYYY
1630
02/09/YYYY
BACTERIOLOGY
OTHER ROUTINE CULTURES
SOURCE:
Throat
SMEAR ONLY:
CULTURE
Normal flora
1st PRELIMINARY
2nd PRELIMINARY
FINAL REPORT
Normal flora
SENSITIVITIES
1.
AMIKACIN
R = Resistant
1.
AMPICILLIN
PENICILLIN G
S = Sensitive
1.
CARBENICILLIN
POLYMYXIN B
› = greater than
1.
CEFAMANDOLE
1.
SULFISOXAZOLE
1.
CEFOXITIN
1.
TETRACYCLINE
1.
CEPHALOTHIN
1.
TRIMETHOPRIM
1.
CHLORAMPHENICOL
1.
NITROFURANTOIN
VANCOMYCIN
CLINDAMYCIN
ERYTHROMYCIN
1.
GENTAMICIN
KANAMYCIN
METHICILLIN
NALIDIXIC ACID
GLOBAL CARE MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
1634
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
SPECIMEN RECEIVED:
SPECIMEN RECEIVED:
02/10/YYYY
02/10/YYYY
URINALYSIS
DIPSTICK ONLY
COLOR
Yellow
SP GRAVITY
1.020
≤ 1.030
ALBUMIN
Negative
≤ 125 mg/dl
BILIRUBIN
Negative
≤ 0.8 mg/dl
ACETONE
Small
≤ 10 mg/dl
BLOOD
Trace
0.06 mg/dl hgb
PH
6
5-8.0
PROTEIN
≤ 30 mg/dl
SUGAR
NEG
NITRITES
NEG
LEUKOCYTE
≤ 15 WBC/hpf
W.B.C.
0
≤ 5/hpf
R.B.C.
No intact RBC
≤ 5/hpf
BACT.
few
1+(≤ 20/hpf)
URINE PREGNANCY TEST
***End of Report***
GLOBAL MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
TIME IN
TIME OUT:
02/09/YYYY 1634
02/09/YYYY 1815
WHITE BLOOD CELL
10.7
4.5-11.0 thou/ul
RED BLOOD CELL
5.17
5.2-5.4 milliliter/ upper limit
HEMOGLOBIN
12.2
11.7-16.1 grams per deciliter
HEMATOCRIT
37.7
35.0-47.0 %
MEAN CORPUSCULAR VOLUME
73.0
85-99 factor level
MEAN CORPUSCULAR HEMOGLOBIN
23.7
MEAN CORPUSCULAR HEMOGLOBIN
CONCENTRATION
32.4
RED CELL DISTRIBUTION WIDTH
PLATELETS
387
33-37
11.4-14.5
130-400 thou/ul
SEGMENTED CELLS %
13
LYMPHOCYTES %
77
20.5-51.1
MONOCYTES %
10
1.7-9.3
EOSINOPHILS %
BAND CELLS %
ATYPICAL LYMPH
Thou/ul= thousand upper limit
COMMENTS:
N/A
***End of Report***
GLOBAL CARE MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
Date of X-ray: 02/09/YYYY
REASON: Rule out pneumonia.
TECHNICAL DATA: Anterior-posterior and lateral elevated 72 inches Pigg-OStat pediatric immobilizer.
REPORT
02/09/YYYY CHEST Anterior-posterior and lateral views show that the lungs
are clear. The heart and pulmonary vascularity are normal.
DD: 02/10/YYYY
Reviewed and Approved: Randall Cunningham MD
ATP-B-S:02:1001261385: Randall Cunningham MD
(Signed:02/10/YYYY 2:24:44 PM EST)
DT: 02/10/YYYY
Physician Authentication
GLOBAL CARE MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
SPECIAL INSTRUCTIONS: N/A
MEDICATION (dose and route)
Amoxicillin 125/5 centimeters
four times a day
DATE: 02/09
TIME
INITIALS
DATE: 02/10
TIME
DATE: 02/11
INITIALS
TIME
INITIALS
12:00
----
12:00
VS
12:00
VS
18:00
24:00
06:00
------JD
18:00
24:00
06:00
OR
JD
JD
18:00
24:00
06:00
OR
JD
----
1650
OR
1215
VS
1720
OR
DATE:
TIME
Single Orders
PRN Medications
Pseudofed 2.5 centimeters 4
times a day as needed for
congestion
Tylenol or Aspirin 1 grain
by mouth or suppository
every 4 hours as needed
INITIALS
SIGNATURE AND TITLE
VT
OR
JD
HF
Vera South, RN
GPW
G. P. Well, RN
Ora Richards, RN
PS
P. Small, RN
Jane Dobbs, RN
H. Figgs, RN
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802
INITIALS
SIGNATURE AND TITLE
INITIALS
SIGNATURE AND TITLE
(607) 555-1234
INITIALS
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
DATE
TIME
TREATMENTS &
MEDICATIONS
02/09/YYYY
1700
Temperature 101.3 Tylenol
60 milligrams by mouth
TIME
NURSES’ NOTES
1615
8-month old white male admitted to room
331 in tent for possible pneumonia. Under
services of Dr. Black. Throat and
Nasopharynx culture done. Blood work and
chest x-ray done. Parents in. Patient’s
face flushed. Hot to touch. Taped for
urinalysis.
1630
1830
2000
Temperature 99.3 Dr. Moore
is in.
2000
2230
Tuesday
Temperature 97
02/10/YYYY
0015
2400
Sudafed 2.5 centimeters
0015
0100
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 02/09/YYYY 04:20:32 PM EST)
Given bottle Gatorade. Took very small
amount of coup. In tent sleeping.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 02/09/YYYY 04:32:09 PM EST)
Sleeping. Respirations even/regular.
Slightly rapid. Occasional congestive
cough. Took small amount of Gatorade.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 02/09/YYYY 06:32:19 PM EST)
Evening care given. In tent. Patient is a
little fussy. Mother with patient.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 02/09/YYYY 08:07:33 PM EST)
Sleeping quietly. Respirations even and
regular.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 02/09/YYYY 10:34:33 PM EST)
Sleeping in croupette. Awakened for vital
signs and medicine. Respirations
congested, rate 36. Occasional congested
cough. Nose irrigated and suctioned as
ordered. Had yellow nasal drainage. Mother
with patient.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 02/10/YYYY 12:03:28 AM EST)
Given for congestion. Back in tent.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 02/10/YYYY 12:17:28 AM EST)
Sleeping. Respirations remain slightly
congested.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 02/10/YYYY 01:03:28 AM EST)
GLOBAL MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
DATE
TIME
TREATMENTS & MEDICATIONS
02/10/YYYY
0800
NURSES’ NOTES
0300
Sleeping. Aspirations slightly congested
with snoring respirations. No cough
presently. Skin cool and dry.
0600
97.4 - 124 - 40
02/10/YYYY
TIME
Regular diet without milk
0800
1000
1200
Regular diet without milk
1200
1400
1530
02/10/YYYY
1700
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 02/10/YYYY 03:04:16 AM EST)
Sleeping. Awakened for vital signs and
medicine. Respirations slightly
congested. Occasional congested cough.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 02/10/YYYY 06:02:56 AM EST)
Mother with patient. Ate fair at
breakfast. Bath given by mother.
Respirations slightly congested. No
cough.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 02/10/YYYY 08:01:28 AM EST)
Sleeping in croupette. Respirations
regular and even.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 02/10/YYYY 10:11:22 AM EST)
Ate well at lunch. Good color – cheerful
– smiling. Visitors with Dr. Moore.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 02/10/YYYY 12:06:18 PM EST)
In croupette sleeping. Respirations
regular. No cough.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 02/10/YYYY 02:03:56 PM EST)
In tent. Mother in. Congestive, loose
cough. Clear nasal discharge. Fussy at
times.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 02/10/YYYY 03:32:11 PM EST)
Took diet fair for supper. Fed by
mother.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 02/10/YYYY 05:05:55 PM EST)
GLOBAL MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
DATE
TIME
TREATMENTS & MEDICATIONS
02/10/YYYY
TIME
NURSES’ NOTES
1830
In tent. Little fussy.
2000
2230
02/11/YYYY
2400
Wednesday
01000500
0600
97.9 – 152 - 36
02/11/YYYY
0800
97.9 – 152 - 36
Regular diet without milk
0800
1000
1200
1300
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 02/10/YYYY 06:31:29 PM EST)
Evening care given. Took Gatorade. In
tent sleeping.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 02/10/YYYY 08:04:19 PM EST)
Sleeping quietly. Respirations even and
regular. Loose congestive cough.
Reviewed and Approved: O. Richards, RN
ATP-B-S:02:1001261385: O. Richards, RN
(Signed: 02/10/YYYY 10:33:33 PM EST)
Sleeping in croup tent. Respirations
easy and regular.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 02/11/YYYY 12:02:16 AM EST)
Sleeping.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 02/11/YYYY 05:00:46 AM EST)
Sleeping in croup tent. Respirations
easy and regular. Had moderate amount of
brown, hard constipated stool.
Reviewed and Approved: J. Dobbs, RN
ATP-B-S:02:1001261385: J. Dobbs, RN
(Signed: 02/11/YYYY 06:02:36 AM EST)
Awake. 1 soft stool. Ate well at
breakfast. Bath given. Dr. Moore in to
exam. Out of tent.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 02/11/YYYY 08:03:00 AM EST)
Content in crib. Tolerates out of tent
well. Clear nasal drainage.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 02/11/YYYY 10:11:48 AM EST)
Ate well at lunch. Parents here. Dr.
Moore in to exam child and talked with
parents. Patient to go home.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 02/11/YYYY 12:06:09 PM EST)
Discharge. Refer to discharge summary
sheet.
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 02/11/YYYY 01:01:01 PM EST)
GLOBAL MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
1.
AFEBRILE:
2.
WOUND:
3.
PAIN FREE:
4.
POST-HOSPITAL INSTRUCTION SHEET GIVEN TO PATIENT/FAMILY:
X
X
Yes
No
Clean/Dry
Reddened
Yes
No
Infected
NA
X
If “No,” describe:
Yes
X
No
If NO, complete lines 5-8 below.
5.
DIET:
X
Regular
6.
ACTIVITY:
X
Normal
7.
MEDICATIONS:
8.
INSTRUCTIONS GIVEN TO PATIENT/FAMILY:
9.
PATIENT/FAMILY verbalize understanding of instructions:
Yes
No
10.
DISCHARGED at
Stretcher
Ambulance Co.
Accompanied by:
X
Other (Describe):
Light
Via:
Wheelchair
Reviewed and Approved: V. South, RN
ATP-B-S:02:1001261385: V. South, RN
(Signed: 02/11/YYYY 01:07:03 PM EST)
1300
Limited
to
Front desk
COMMENTS:
GLOBAL MEDICAL CENTER
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
Bed rest
WEST, KEITH
Admission:02/09/YYYY
IPCase010
DOB: 05/23/YYYY
Dr. BLACK
ROOM: 331
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: Kelly West
ATP-B-S:02:1001261385: Kelly West
(Signed: 02/09/YYYY 04:36:44 PM EST
Signature of Parent or Guardian of Patient
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 02/09/YYYY 04:37:00 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: Kelly West
ATP-B-S:02:1001261385: Kelly West
(Signed: 02/09/YYYY 04:36:59 PM EST
Signature of Parent or Guardian of Patient
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 02/09/YYYY 04:38:28 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