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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