| 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 8 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 242 241 240 239 238 237 236 235 234 233 232 231 230 229 228 227 Blood Pressure am 129/61 130/61 122/67 127/64 118/66 122/66 131/70 126/63 125/71 135/71 128/62 121/65 118/69 130/66 128/60 125/65 pm 146/79 138/68 148/77 130/73 132/62 135/87 141/81 143/71 128/76 139879 122/714 128/60 136/74 125/71 126/64 124/72 Pulse am 74 78 71 82 83 78 73 78 84 79 74 77 73 76 75 71 pm 82 76 74 81 79 77 89 86 83 71 78 68 81 74 66 69 Respiratory Rate 14 12 13 14 13 14 12 14 13 143 12 12 14 14 13 12 Wt (kg [lb])
See Historical Weight Graph140
63.6 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 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)B-Hearing-Speech-Vision (Completed - 8 Month)K-Swallowing-Nutritional Status (Use your completed MDS Section K)Care Area Assessments (CAA)
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+ ASSESSMENTS
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Date and Time Type of Assessment Author Day Dietitian Day Nurse Day Nurse Day Nurse Day Nurse Day Admission Nurse
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+ PROGRESS NOTE
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Date/Time Progress Note Provider Day 242 Resident satisfied with aspects of daily life, no issues Day shift nurse Day 241 Resident ate all food provided at evening meal, slept uninterrupted Night shift nurse Day241 Satisfied with food and daily life, no problems Day shift nurse Day 240 Checked on resident. Sleeping well, breathing normally. No issues or questions Night shift nurse Day 240 Resident likes social aspects of facility, no problems or questions Day shift nurse Day239 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day239 Resident comfortable with living arrangements, loves the food, no questions Day shift, Director Of Nursing (DON) Day 239 Checked resident. Eyes closed, breathing normally. No problems Night shift nurse Day 238 No questions, resident expressed satisfaction with staff and activities Day shift nurse Day 238 Checked on resident. Slept most of night, awake once, checked later--eyes closed, breathing normally. No problems Night shift nurse Day 238 Resident questions about visitors answered, no issues Day shift nurse Day 237 Checked on resident. Sleeping peacefully, breathing normally. No problems Night shift nurse Day 237 Resident satisfied, no problems Day shift nurse Day 236 Checked on resident. Sleeping, breathing normally. No issues Night shift nurse Day 236 Resident eating well, satisfied, no problems Day shift nurse Day 235 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 235 Resident has no issues or questions Day shift nurse Day 234 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 234 Resident routine being followed Day shift nurse Day 233 Resident enjoying food, sleeping well, breathing normally Night shift nurse Day 233 Resident happy with daily routine, no questions Day shift nurse Day 232 Sleeping well, eyes closed, breathing Night shift nurse Day 232 Resident Day shift nurse Day 231 Checked on resident. Eyes closed, breathing normally. No problems Night shift staff Day 231 Resident routine reviewed, satisfied with facility and services, questions answered Day shift, Director Of Nursing (DON) Day 231 Resident enjoying routine, no questions Day shift nurse Day 230 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 230 Resident routine going well, no problems Day shift Day 229 Checked on resident. Eyes closed, breathing normally. No problems Night shift Day 229 Resident satisfied with everything, no issues Day shift Day 228 Sleeping well, eyes closed, breathing Night shift Day 228 Resident enjoying food and visitors Day shift Day 227 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 Day 14 Dietitian CAA # 12 Your Name Within 7 days Physicians Assessment Myers, MD Within 7 days Dietitians Initial Assessment (your completed assignment) YOUR NAME Your Name
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Updated February 19, 2024