| ELECTRONIC HEALTH RECORD |  |
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| Bertha S Jones | Gender: Female | 85 yrs | DOB: 03/22/193x | Pref Lang: English | ||||
| Allergies: NKA | ||||
| MRN: 79684 | CSN: 323567098 Room 216 | ||||
| Long Term Care Resident Admission |
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+ PATIENT PROFILE
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+ MEDICAL DIAGNOSIS
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Ongoing Problem ListMEDICAL DIAGNOSIS/PROBLEM Date Opened Status Unspecified Dementia/Mild Cognitive Impairment (ICD-10 F 03.9) Past x 2 yrs Open Hypothyroidism (ICD-10 E 039) Past x 20 yrs Open Gastro-esophageal Reflux Disease (GERD) (ICD-10 K 21.9) Past x 5 yrs Open Essential Hypertension (ICD-10 I 10) Past x 10 yrs Open Constipation (ICD-10 K 59.0) Past x 5 yrs Open Hypercholesterolemia (ICD-10 E 78) Past x 5 yrs Open Urinary Tract Infection (UTI) (ICD-10 N 39.0) Upon admission to hospital Open
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+ ALLERGY
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No known allergies
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+ IMMUNIZATION
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TB test upon admission
Pneumonia and flu shots — during hospitalization
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+ ORDERS
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Physician Orders, Scheduled
Name Dose Route Frequency Start Namenda 10 mg tab po 0900 - daily Admission Synthroid 25 mcg po 0600 - daily Admission Omeprazole 20 mg tab po 0900 - daily B12 1000 mcg tab po 0900 - daily Metoprolol tartrate 25 mg tab po 0900
2100
Check Pulse and BP before administering medication; Hold medication if pulse <60; BP Sysstolic <100 Iron Sulfate 325 mg po 0900 Vitamin C 500 mg tab po 0900 Cranberry Tab 325 mg po 0900 Senna S 8 mg - 50 mg tab po 0900
2100
Chewable asprin 81 mg po hs Atorvastatin 10 mg po hs Diltiazem 120 mg po hs Timolol Meleate 0.5% eye drops (1 gtt) in both eyes 0900
2100
Levaquin 500 mg po daily Admission for 5 days Diet Order: No Added Salt
Consultations
Referral Date Ordered Date Completed
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+ VITALS AND WEIGHT
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Item Name Shift Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Blood Pressure am 130/60 115/75 pm 126/73 139/79 Pulse am 76 74 pm 75 80 Respiratory Rate Wt (lb [kg])
No Historical Weight Graph Available136.5 lbs
(62 kg)
Ht (inches [cm]) 62 inches (157.4 cm) BMI (kg/m2) 25
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+ RESULTS
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Biochemical Data and Medical Tests and Procedures
Test Hospital Long Term Care Facility Comments Electrolyte and
Renal ProfileWhite Cell Profile
Gastrointestinal Profile
Glucose/
Endocrine ProfileRandom Glucose 121 Inflammatory Profile
Nutritional Anemia ProfileProtein Profile Total Protein 7.9 Albumin 3.6 Lipid Profile Images: Emergency department
Hip and Pelvic X-Ray results: Negative
Chest X-ray: Negative
Head CT Scan: No bleed or other acute intracranial abnormality demonstrated. No new non-acute changes.
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+ RESIDENT ASSESSMENT INSTRUMENT — Minimum Data Set (MDS) 3.0 and Care Area Assessments (CAA)
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Minimum Data Set (MDS)
Care Area Assessments (CAA)
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+ ASSESSMENTS
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Date and Time Type of Assessment Author Day 1 Admission Nurse Day 3 Admission Braden Scale-For Predicting Pressure Sore Risk completed Nurse Day 3 Admission Fall Risk Evaluation completed Nurse Day 3 Abnormal Involuntary Movement Scale (AIMS) completed Nurse Day 3 ADL Functional/Restorative Record completed Nurse
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+ PROGRESS NOTE
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Date and Time Progress Note Provider Admission date Arrival via transport accompanied by driver and daughter.
Admitted to Room 216. Skin check completed.
Oriented to room, toilet, dining room, eating environment, floor.
Call bell left within reach.
Continent.
Vitals: BP 131/62, Pulse 77, RR 13.
Has UTI. Status post fall.
Safety precautions in place.Admission nurse Day 2 (night shift) Checked on resident. Eyes closed, breathing normally. No problems. Night shift nurse
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+ CARE PLAN
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Baseline Care Plan
BASELINE CARE PLAN: Bertha S Jones
MRN: 79684 | CSN: 323567098 No Allergies Code Status (Living Will Declaration on File) Room 216
Initial Goals Dietary Orders Therapy Services Social Services Discharge to community
Remain LTC
Other
Resident Information:Resident preferred name: Bertha
Cognition:
Alert/cognitively intact
Confused
Elopement risk
Intervention: ___________________________
Communication:
Verbal
Non-verbal
Preferred language or method of communication
___________________________
Vision:Vision adequate
Vision impaired (glasses)
Appliance
Hearing:
Hearing adequate
Hearing impaired
Appliance
Communication, hearing or vision risk:
Interventions
Regular No Added Salt
TPN or tube feeding
IV fluids
__________________________________
Resident's dietary preferences:
Dietary risks:
Risk for weight loss
Risk for swallowing problems
Risk for chewing problems
Resident's dietary goal:
Maintain current weight
Prevent weight loss
Dietary Interventions:
Eats in dining area
Eats in room
Dentures or partials
Specialty utensils or devises
Other
Physical Therapy (PT)
Occupational Therapy (OT)
Speech Language Program (SLP)
Restorative:
Program(s)
Resident's functional goals:Maintain current functional status
Improvement:
Decline:
Functional Intervention:
___________________________
Mental health needs: ___________________________
Behavior concerns: ___________________________
PASRR (Level II recommendation):
____________________________
Depression screening
Able to recognize need for placement in residential care
Resident's psychosocial goals:
___________________________
___________________________
Social Services/psychosocial interventions:
Behavioral interventions
___________________________
SAFETY History of falls: ___________________________
History of fall-related injury
ADLs (Activities of Daily Living) Bed mobility: Independent
Assist 2+
Setup
Total dependence
Assist of 1
N/A
Locomotion: Independent
Assist 2+
Setup
Total dependence
Assist of 1
N/A
Transfer: Independent
Assist 2+
Setup
Total dependence
Assist of 1
N/A
Eating: Independent
Assist 2+
Setup
Total dependence
Assist of 1
N/A
Walking: Independent
Assist 2+
Setup
Total dependence
Assist of 1
N/A
Grooming/
hygiene:Independent
Assist 2+
Setup
Total dependence
Assist of 1
N/A
Toileting: Independent
Assist 2+
Set up
Total dependence
Assist of 1
N/A
Bathing: Independent
Assist 2+
Setup
Total dependence
Assist of 1
N/A
Equipment: Special Treatment/Procedures Transfusions
Radiation
Chemotherapy: _____________________
IV medication: _____________________
Type: _____________________
Location: _____________________
Dressing change: _____________________
Ventilator
Tracheostomy
Cannula size:
Suction
Oxygen
Liters per minute:
BiPAP
Liters per minute:
CPAP
Liters per minute:
Isolation/quarantine for: _____________________
Other Treatment/procedure
_________________________
_________________________
_________________________
_________________________
Bowel and Bladder Skin Concerns Other Conditions Other Conditions Bowel:
Continent
Incontinent
Appliance
Bladder:
Continent
Incontinent — at times
Appliance
Incontinence briefs or pads
Size: Medium
Bowel and bladder risk:
Risk for incontinence
Bowel and bladder goal:
__________________
Bowel and bladder interventions:
_______________________
Skin intact
Current pressure ulcer
Other skin concern or wound:
Wound vac
Skin break risk:
___________________________
Resident's skin integrity goal:
_____________________________
Skin break Interventions:
Turn and reposition
Specialty mattress
Cushions and wedges
Skin and wound treatments
Other: _______________________
_________________________
Risk:
____________________________
Goal:
_____________________________
Intervention:
_____________________________
_________________________
Risk:
____________________________
Goal:
_____________________________
Intervention:
_____________________________
Alarm
Restraint: _______________________
Medical symptom to justify use: mild cognitive decline
Alarm/restraints reduction goals:
Maintain current alarm/restraint as ordered
Reduction plan
Resident/representative decline, education provided
Resident's life history notes prior to residing in nursing home:
Living alone. Fell prior to hospital stay.
Resident's daily routine and preferences:
Ate meals on her own and cared for self.
Resident's cultural and ethnic preferences:
Physician Orders Discharge Plans See current Management and Administrative Reporting (MAR) and Treatment Authorization Request (TAR)
Current medication list provided to resident/representative
Medication list reconciled with resident/representative
Self-administer medications
Location: _____________________________
Caregiver: _____________________________
Equipment needed: _____________________________
Home Services: _____________________________
Medications Barriers to Resident's Discharge Goals High risk/black box medication: _______________________
Insulin: _______________________
Blood glucose checks: _______________________
Psychotropic medication: _______________________
Adverse effects: _______________________
Anticoagulants: _______________________
Lab monitoring: _______________________
Monitor for s/s of uncontrolled bleeding
Antibiotics: _______________________
Pharmacological pain regimen
Resident or Caregiver Educational Needs Hospice Coordinator Other medications Outside Coordination Hemodialysis (provider, schedule, transport, meal prep required)
Written Summary of Baseline Care Plan Day 1 — Resident admitted to facility after fall with UTI on ABT (antibiotic therapy). No adverse reaction to ABT. Feeds self after tray set-up. Intake good. (Signature)
Day 2 — (ENTER DIETITIANS NOTE HERE IN SAME FORMAT AS NURSES NOTE ABOVE)
Nutrition Care Plan — Use your Completed Nutrition Care Plan when one is completed.
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+ TASKS
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First 4 days and then schedule (Find DR Orders)
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Date and Time Type of Encounter Author Within 7 days Physicians Assessment Myers, MD Within 7 days Dietitians Initial Assessment
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