Skip to Content

LTC-Electronic Health Record - 90 days

 ELECTRONIC HEALTH RECORD
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 90
+ PATIENT PROFILE

HIPPA Form

Advanced Directive

PreAdmission Screen

 

+ MEDICAL DIAGNOSIS

 
Ongoing Problem List

MEDICAL 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

 
+ ALLERGY

No known Allergies
 
+ IMMUNIZATION


TB test upon admission
Pneumonia and Flue shots  - during hospitalization
 
 
+ ORDERS

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
     

 

+ VITALS AND WEIGHT

 

Item Name Shift 90 89 88 87 86 85 84 83 82 81 80 79 78 77 76 75
Blood Pressure  am 128/60 132/61 120/68 128/63 116/66 123/67 133/70 125/64 126/70 136/72 126/63 123/65 115/69 131/66 129/61 125/66
pm 149/78 138/68 149/77 130/73 133/62 135/87 140/81 143/71 129/76 139/79 122/714 129/60 136/74 126/71 127/64 124/72
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   13 13 13 14 12 13 12 12 13 14 12 12 14 14 13 12
Wt (kg [lb])

See Historical Weight Graph

 

152.2

69.1 kg

            

 

      

 

 

 

    
Ht (cm [ft])                              
BMI (kg/m2)   27.9                              

+ RESULTS
 

Biochemical Data and Medical Tests and Procedures

  Test Hospital Long Term Care Facility Comments
Electrolyte and
Renal Profile		        
       
       
       
White Cell Profile          



Gastrointestinal Profile 		     

 
     
     
     
       
       
Glucose/
Endocrine Profile		 Random Glucose 121    
Inflammatory Profile         

Nutritional Anemia Profile		        
       
       
       
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

 

+ Resident Assessment Instrument (Minimum Data Set (MDS) 3.0 and Care Area Assessments (CAA))
Minimum Data Set (MDS)
 
K-Swallowing-Nutritional Status (Use your completed MDS Section K)
 
Care Area Assessments (CAA)
+ ASSESSMENTS
 
Date and Time Type of Assessment Author
  Day 90 Team assessments being completed at 90 days, most not in record yet  
Day 7 Dietitian Initial Assessment (YOUR DOCUMENT) Dietitian
+ PROGRESS NOTE
Date/Time Progress Note Provider
Day 90  Completed assessment, discussed with daughter, Bertha will become permanent resident  Social worker
Day 90 Resident satisfied with aspects of daily life, no issues Day shift nurse
Day 89 Resident ate all food provided at evening meal, slept uninterrupted Night shift nurse
Day 89 Satisfied with food and daily life, no problems Day shift nurse
Day 88  Checked on resident.  Sleeping well, breathing normally.  No issues or questions Night shift nurse
Day 88 Resident likes social aspects of facility, no problems or questions Day shift nurse
Day 87  Checked on resident.  Eyes closed, breathing normally.  No problems Night shift nurse
Day 87 Resident comfortable with living arrangements, loves the food, no questions Day shift, Director Of Nursing (DON)
Day 86  Checked resident.  Eyes closed, breathing normally.  No problems Night shift nurse
Day 86 No questions, resident expressed satisfaction with staff and activities Day shift nurse
Day 85  Checked on resident.  Slept most of night, awake once,  checked later--eyes closed, breathing normally.  No problems Night shift nurse
Day 85 Resident questions about visitors answered, no issues Day shift nurse
Day 84  Checked on resident.  Sleeping peacefully, breathing normally.  No problems Night shift nurse
Day 84 Resident satisfied, no problems Day shift nurse
Day 83  Checked on resident.  Sleeping, breathing normally.  No issues Night shift nurse
Day 83 Resident eating well, satisfied, no problems Day shift nurse
Day 82  Checked on resident.  Eyes closed, breathing normally.  No problems Night shift nurse
Day 82 Resident has no issues or questions Day shift nurse
Day 81  Checked on resident.  Eyes closed, breathing normally.  No problems Night shift nurse
Day 81 Resident routine being followed Day shift nurse
Day 80 Resident enjoying food, sleeping well, breathing normally Night shift nurse
Day 80 Resident happy with daily routine, no questions Day shift nurse
Day 79 Sleeping well, eyes closed, breathing  Night shift nurse
Day 79  Resident  Day shift nurse
Day 78  Checked on resident.  Eyes closed, breathing normally.  No problems Night shift staff
Day 78 Resident routine reviewed, satisfied with facility and services, questions answered Day shift, Director Of Nursing (DON)
Day 78  Resident enjoying routine, no questions Day shift nurse
Day 77 Checked on resident.  Eyes closed, breathing normally.  No problems Night shift nurse
Day  77 Resident routine going well, no problems Day shift
Day 76 Checked on resident.  Eyes closed, breathing normally.  No problems Night shift
Day 76 Resident satisfied with everything, no issues Day shift
Day 75 Sleeping well, eyes closed, breathing  Night shift
Day 75 Resident enjoying food and visitors Day shift
Day 74 Checked on resident, sleeping peacefully, no issus Night shift

Montly Nutrition Progress Note (Re-Assessment - Monitoring and Evaluation Form - (USE YOUR COMPLETED ACTIVITY)

 

+ CARE PLAN
 


Nutrition Care Plan (USE YOUR COMPLETED ACTIVITY)

 

+ TASKS

First 4 days and then schedule (Find DR Orders)

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
     

 

 

Updated February 19, 2024
Exit Full Screen