| 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 7 MONTHS |
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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 212 211 210 209 208 207 206 205 204 203 202 201 200 199 198 197 Blood Pressure am 129/61 130/61 122/68 126/63 118/66 112/67 132/70 186/64 125/70 136/72 127/63 121/65 118/69 130/66 129/61 125/66 pm 145/79 138/68 148/77 130/73 132/62 135/87 140/81 143/71 189/76 138/79 121/714 128/60 135/74 126/71 126/64 123/72 Pulse am 73 78 70 82 82 78 73 79 84 78 74 78 73 77 75 71 pm 82 75 74 80 79 79 87 86 82 71 79 68 80 74 66 69 Respiratory Rate 14 13 13 14 12 14 12 12 13 14 12 12 14 14 13 12 Wt (kg [lb])
See Historical Weight Graph149.1
67.8 kg
Ht (cm [ft]) BMI (kg/m2) 27.3
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+ RESULTS
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Biochemical Data and Medical Tests and Procedures
Test Hospital Long Term Care Facility-6 mo Comments Electrolyte and
Renal ProfileWhite Cell Profile
Gastrointestinal Profile
Glucose/
Endocrine ProfileRandom Glucose 121 Inflammatory Profile
Nutritional Anemia ProfileHemoglobin 12.4 Hematocrit 36.9 Protein 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 MDS Section K)Care Area Assessments (CAA)
2. Cognitive Loss - Completed during 6 month assessments
5. Activities of Daily Living (ADL) - Funcational Status
6. Urinary Incontinence and Indwelling Catheter
12. Nutrition Status (Use your completed CAA 12)
14. Dehydration/Fluid Maintenance
17. Psychotropic Medication Use
20. Return to Community Referral
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+ ASSESSMENTS
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Date and Time Type of Assessment Author 6 month CAA 2 Cognitive Registered Nurse
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+ PROGRESS NOTE
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Date/Time Progress Note Provider Day 212 Resident satisfied with aspects of daily life, no issues Day shift nurse Day 212 Resident wasn't hungry at evening meal, slept uninterrupted Night shift nurse Day 211 Satisfied with food and daily life, no problems Day shift nurse Day 211 Checked on resident. Sleeping well, breathing normally. No issues or questions Night shift nurse Day 210 Resident likes social aspects of facility, no problems or questions Day shift nurse Day 210 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 209 Resident comfortable with living arrangements, loss of appetite, no questions Day shift, Director Of Nursing (DON) Day 209 Checked resident. Eyes closed, breathing normally. No problems Night shift nurse Day 209 No questions, resident expressed satisfaction with staff and activities Day shift nurse Day 210 Checked on resident. Slept most of night, awake once, checked later--eyes closed, breathing normally. No problems Night shift nurse Day 210 Resident questions about visitors answered, no issues Day shift nurse Day 210 Checked on resident. Sleeping peacefully, breathing normally. No problems Night shift nurse Day 209 Resident satisfied, no problems Day shift nurse Day 209 Checked on resident. Sleeping, breathing normally. No issues Night shift nurse Day 208 Resident eating well, satisfied, no problems Day shift nurse Day 208 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 207 Resident has no issues or questions Day shift nurse Day 207 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 206 Resident routine being followed Day shift nurse Day 206 Resident enjoying food, sleeping well, breathing normally Night shift nurse Day 205 Resident happy with daily routine, no questions Day shift nurse Day 205 Sleeping well, eyes closed, breathing Night shift nurse Day 206 Resident Day shift nurse Day 206 Checked on resident. Eyes closed, breathing normally. No problems Night shift staff Day 206 Resident routine reviewed, satisfied with facility and services, questions answered Day shift, Director Of Nursing (DON) Day 205 Resident enjoying routine, no questions Day shift nurse Day 205 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 204 Resident routine going well, no problems Day shift Day 204 Checked on resident. Eyes closed, breathing normally. No problems Night shift Day 203 Resident satisfied with everything, no issues Day shift Day 203 Sleeping well, eyes closed, breathing Night shift Day 202 Resident enjoying food and visitors Day shift Day 202 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)
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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
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Updated February 19, 2024