| 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 Day 14 |
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+ PATIENT PROFILE
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+ MEDICAL DIAGNOSIS
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Ongoing Problem ListMEDICAL DIAGNOSIS/PROBLEM Date Opened Status Unspsecified Dementia/Mild Cognitive Impairment (ICD-10 F 03.9) Past 2 yrs Open Hypothyroidiism (ICD-10 E 039) Past x 20 yrs Open Gastro-esophageal Reflux Disease (GERD) (ICD-10 K 21.9) Past x 5 years Open Essential Hypertension (ICD-10 I 10) Past x 10 yrs Open Constipation (ICD-10 K 59.0) Past 5x yrs Open Hypercholesterolemia (ICD-10 E 78) Past x 5 yrs Open Urinary TractInfection (UTI) (ICD-10 N 39.0) Upon Admission to hospital Resolved
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+ ALLERGY
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No known Allergies
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+ IMMUNIZATION
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TB test upon admissionPneumonia and Flue 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 Metoprotol tatrate 25 mg tab po 0900
2100
Check Pulse and BP beefore administering medication; Hold medication if pulse <60; BP Systolic <100 Iron Sulfate 325 mg po 0900 Vitamin C 500 mg tab po 0900 Cranberry Tab 325 mg po 0900 Senna S 8.mg-50mg 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 Discontinued Day 5 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 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Blood Pressure am 128/64 132/60 120/68 128/62 113/67 126/68 136/72 126/66 126/70 136/71 126/60 122/61 115/75 130/60 pm 149/80 128/68 153/79 130/76 134/61 136/87 145/80 144/71 128/76 139/82 124/75 129/60 139/79 126/73 Pulse am 74 80 72 80 84 74 64 84 84 78 75 77 74 76 pm 82 76 74 82 79 78 90 86 84 69 78 60 80 75 Respiratory Rate 12 14 13 13 14 12 14 12 12 13 13 12 12 13 14 Wt (kg [lb])
See Historical Weight Graph139.5 lb
63.4 kg
139.5 lb
63.4 kg
138.4 lb
62.9 kg
136.5 lbs
(62 kg)
Ht (cm [ft]) 62 inches ((157.4 cm) BMI (kg/m2) 25.5 25.2 25.3 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 intracaranial abnormality demonstrateed. 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 13 Social work - Goal - determine if Bertha can return to independent living in future Social worker Day 7 Dietitian Initial Assessment (YOUR DOCUMENT) Dietitian Day 3 ADL Functional/Restorative Record completed Nurse Day 3 Abnormal Involuntary Movement Scale (AIMS) completed Nurse Day 3 Admission Fall Risk Evaluation completed Nurse Day 3 Admission Braden Scale-For Predicting Pressure Sore Risk completed Nurse Day 1 Admission Nurse
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+ PROGRESS NOTE
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Date/Time Progress Note Provider Day 14 Initial speech and language assessment indicates no problems requiring intervention at this time. Re-evaluate quarterly Speech Language Day 14 Bertha is not ready to consider independent living-will re-assess at 90 days Social Worker Day 14 Resident satisfied with aspects of daily life, no issues Day shift nurse Day 13 Physical Therapy evaluation completed and daily PT beginning Phsical Therapist Day 13 Resident eating all food provided, slept uninterrupted Night shift nurse Day 13 Hospice evaluation completed, not warranted at this time Hospice nurse Day 13 Satisfied with food and daily life, no problems Day shift nurse Day 12 Occupational therapy evaluation completed, no issues at this time Occupational therapist Day 12 Checked on resident. Sleeping well, breathing normally. No issues or questions Night shift nurse Day 12 Resident likes social aspects of facility, no problems or questions Day shift nurse Day 11 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 11 Resident comfortable with living arrangements, enjoying food, no questions Day shift, Director Of Nursing (DON) Day 10 Checked resident. Eyes closed, breathing normally. No problems Night shift nurse Day 10 No questions, resident expressed satisfaction with staff and activities Day shift nurse Day 9 Checked on resident. Slept most of night, awake once, checked later--eyes closed, breathing normally. No problems Night shift nurse Day 9 Resident questions about visitors answered, no issues Day shift nurse Day 8 Checked on resident. Sleeping peacefully, breathing normally. No problems Night shift nurse Day 8 Resident satisfied, no problems Day shift nurse Day 7 Checked on resident. Sleeping, breathing normally. No issues Night shift nurse Day 7 Resident eating well, satisfied, no problems Day shift nurse Day 6 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 6 Resident has no issues or questions Day shift nurse Day 5 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 5 Resident routine being established Day shift nurse Day 4 Resident enjoying food, sleeping well, breathing normally Night shift nurse Day 4 Resident settled in, no questions Day shift nurse Day 3 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 3 Residents questions answered, settling into routine Nursing staff Day 2 (day shift) Resident oriented to facility and services, questions answered Day shift, Director Of Nursing (DON) Day 1 (night shift) Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Admission date Arrival via transport accompanied by driver and daufhter. 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 Montly Monitoring and Evaluation Risk Tracking Form &/or Dietitian's Initial Assessment - SEE YOUR ACTIVITY YOU STARTED AT ADMISSION
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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
Resident and DTS have met with resident and she is selecting menu items
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
Select menu provided
Physical Therapy (PT) - 1 x day - strengthening
Occupational Therapy (OT)
Speech Language Program (SLP)
Restorative
Program(s)
Resident's functional goals
Maintain current functional status
Improvement: Ambulatory
Decline:
Functional Intervention
_______PT 1x day__________
Mental health needs________________________
Behavior concerns:
______________________________
PASRR (Level II recommendation)
____________________________
Depression screening
Able to recognize need for placement in residentical 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
Bowe and bladder goal
__________________
Bowel and bladder intervntions
_______________________
Skin intact
Current pressure ulcer
Other skin concern or wound:
Wound vac
Skin Break Risk
___________________________
Resident's sking integrity goal
_____________________________
Skin break Interventions
Turn and reposition
Specialty mattress
Cusions 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 ownand cared for self
Resident's cultural and enthic preferences:
Physician Orders Discharge Plans See current Management and Adminisrative Reporting (MAR) and Treatment Authorization Request (TAR)
Current medicataion list provided to resident/representative
Medication list reconciled with resident/represesntative
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 efects:_________________________________________
Anticoagulants:___________________________________________
Lab monitoring:________________________________________
Monitor for s/s of uncontrolled bleeding
Antibiotic:_______________________________________________
Pharmacological pain regimen
Resident or Caregiver Educationa Needs Hospice Coordinator Other medications Outside Coordination Hemodialysis (provider, schedule, transport, meal prep required)
Written Summary of Baseline Care Plan Day 7 (Your previous dietitian's note) 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)
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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 (your completed assignment) YOUR NAME Within 7 days Physical Therapy Assessment
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