| 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 10 MONTHS |
-
+ PATIENT PROFILE
-
-
+ MEDICAL DIAGNOSIS
-
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
-
+ ALLERGY
-
No known Allergies
-
+ IMMUNIZATION
-
TB test upon admissionPneumonia 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/Puree Level 4, House 2.0 supplement followed by 120 Ml water, Fluids Level 0
Consultations
Referral Date Ordered Date Completed
-
+ VITALS AND WEIGHT
-
Item Name Shift 303 302 301 300 299 298 297 296 295 294 293 292 291 290 289 288 Blood Pressure am 129/61 130/61 123/68 127/63 118/66 124/67 132/70 127/64 122/70 134/72 127/63 126/65 122/69 128/66 169/61 124/66 pm 147/79 138/68 149/77 130/73 133/62 135/87 140/81 143/71 129/76 139/79 122/714 129/60 136/74 126/71 127/64 124/72 Pulse am 74 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 13 13 14 12 14 12 12 13 14 12 12 14 14 13 12 Wt (lb, kg)
See Historical Weight Graph131.9
60.4 kg
132.2
60 kg
132
59.9 kg
Ht (cm [ft]) BMI (kg/m2) 24.1 24.2 24.2
-
+ RESULTS
-
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
-
+ 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 298 MDS Section C Cognitive Function was completed Floor Nurse Day 297 Retorative Dining Report Restorative Dining CNA Day Nurse Day Nurse Day Nurse Day Admission Nurse
-
+ PROGRESS NOTE
-
Date/Time Progress Note Provider Day 303 Bertha is tired, but satisfied with aspects of daily life Day shift nurse Day 303 Resident ate some of pureed food provided at evening meal, slept uninterrupted Night shift nurse Day 303 Satisfied with food and daily life, no problems Day shift nurse Day 302 Checked on resident. Sleeping well, breathing normally. No issues or questions Night shift nurse Day 302 Resident likes social aspects of facility, no problems or questions Day shift nurse Day 301 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 301 Resident comfortable with living arrangements, no questions Day shift, Director Of Nursing (DON) Day 299 Checked resident. Eyes closed, breathing normally. No problems Night shift nurse Day 299 No questions Day shift nurse Day 298 Checked on resident. Slept most of night, awake once, checked later--eyes closed, breathing normally. No problems Night shift nurse Day 298 Resident comfortable, no issues Day shift nurse Day 297 Checked on resident. Sleeping peacefully, breathing normally. No problems Night shift nurse Day 297 Resident satisfied, no problems Day shift nurse Day 296 Checked on resident. Sleeping, breathing normally. No issues Night shift nurse Day 296 Resident consuming some food and beverage, satisfied, no problems Day shift nurse Day 295 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 295 Resident has no issues or questions Day shift nurse Day 294 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 294 Resident routine being followed Day shift nurse Day 293 Resident sleeping well, breathing normally Night shift nurse Day 293 Resident happy with daily routine, no questions Day shift nurse Day 292 Sleeping well, eyes closed, breathing Night shift nurse Day 292 Resident Day shift nurse Day 291 Checked on resident. Eyes closed, breathing normally. No problems Night shift staff Day 291 Resident routine reviewed, satisfied with facility and services, questions answered Day shift, Director Of Nursing (DON) Day 291 Resident enjoying routine, no questions Day shift nurse Day 290 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 290 Resident routine going well, no problems Day shift Day 289 Checked on resident. Eyes closed, breathing normally. No problems Night shift Day 289 Resident satisfied with everything, no issues Day shift Day 288 Sleeping well, eyes closed, breathing Night shift Day 288 Resident enjoying visitors but limited interaction Day shift Day 287 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