| 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 60 |
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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 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-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
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 60 59 58 57 56 55 54 53 52 51 50 49 48 47 46 47 Blood Pressure am 128/63 132/62 120/69 128/62 115/67 123/68 133/71 126/65 126/71 136/70 126/65 122/67 115/71 130/61 129/62 125/60 pm 149/78 128/68 153/79 130/73 134/62 135/87 140/82 143/71 129/76 139/81 123/714 129/60 136/75 126/71 127/64 124/72 Pulse am 74 79 72 81 84 74 71 77 84 78 74 77 72 76 75 71 pm 82 76 74 82 79 78 89 86 84 71 78 67 80 74 66 69 Respiratory Rate 14 13 13 14 12 14 12 12 13 13 12 12 13 14 13 12 Wt (kg [lb])
See Historical Weight Graph145.4
66.1 kg
Ht (cm [ft]) BMI (kg/m2) 26.6
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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)
K-Swallowing-Nutritional Status (Use your completed Admission MDS Section K)Care Area Assessments (CAA)
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+ ASSESSMENTS
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Date and Time Type of Assessment Author 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 60 Resident satisfied with aspects of daily life, no issues Day shift nurse Day 59 Resident ate all food provided at evening meal, slept uninterrupted Night shift nurse Day 59 Satisfied with food and daily life, no problems Day shift nurse Day 58 Checked on resident. Sleeping well, breathing normally. No issues or questions Night shift nurse Day 58 Resident likes social aspects of facility, no problems or questions Day shift nurse Day 57 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 57 Resident comfortable with living arrangements, loves the food, no questions Day shift, Director Of Nursing (DON) Day 56 Checked resident. Eyes closed, breathing normally. No problems Night shift nurse Day 56 No questions, resident expressed satisfaction with staff and activities Day shift nurse Day 55 Checked on resident. Slept most of night, awake once, checked later--eyes closed, breathing normally. No problems Night shift nurse Day 55 Resident questions about visitors answered, no issues Day shift nurse Day 54 Checked on resident. Sleeping peacefully, breathing normally. No problems Night shift nurse Day 54 Resident satisfied, no problems Day shift nurse Day 53 Checked on resident. Sleeping, breathing normally. No issues Night shift nurse Day 53 Resident eating well, satisfied, no problems Day shift nurse Day 52 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 52 Resident has no issues or questions Day shift nurse Day 51 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 51 Resident routine being followed Day shift nurse Day 50 Resident enjoying food, sleeping well, breathing normally Night shift nurse Day 50 Resident happy with daily routine, no questions Day shift nurse Day 49 Sleeping well, eyes closed, breathing Night shift nurse Day 49 Resident Day shift nurse Day 48 Checked on resident. Eyes closed, breathing normally. No problems Night shift staff Day 48 Resident routine reviewed, satisfied with facility and services, questions answered Day shift, Director Of Nursing (DON) Day 48 Resident enjoying routine, no questions Day shift nurse Day 47 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 47 Resident routine going well, no problems Day shift Day 46 Checked on resident. Eyes closed, breathing normally. No problems Night shift Day 46 Resident satisfied with everything, no issues Day shift Day 45 Sleeping well, eyes closed, breathing Night shift Day 45 Resident enjoying food and visitors Day shift Day 44 Checked on resident, sleeping peacefully, no issus Night shift Montly Nutrition Progress Note (Re-Assessment - Monitoring and Evaluation Form - (USE YOUR COMPLETED ACTIVITY)
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+ CARE PLAN
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Nutrition Care Plan (USE YOUR COMPLETED ACTIVITY)+ TASKSFirst 4 days and then schedule (Find DR Orders)
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 Day 14 Dietitian CAA Your Name
Updated February 19, 2024