| 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 12 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/Puree Level 4, House 2.0 supplement followed by 120 Ml water, Fluids Level 0
Referral Date Ordered Date Completed Hospice Consult Yesterday Yesterday Consultations
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+ VITALS AND WEIGHT
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Item Name Shift 364 363 362 361 360 359 358 357 356 355 354 353 352 353 352 351 Blood Pressure am 129/61 131/61 122/68 127/63 118/66 122/67 132/70 126/64 125/70 135/72 127/63 121/65 118/69 130/66 129/61 125/66 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 (kg [lb])
See Historical Weight Graph154
69.8 kg
Ht (cm [ft]) BMI (kg/m2) 28.2
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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 MDS Section K)Care Area Assessments (CAA)
2. Cognitive Loss (Completed 12 month)
5. Activities of Daily Living (ADL) - Funcational Status (Completed between 11 and 12 Month)
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 Day 364 Hospice Assessment completed Hospice Company Day 359 Restorative Dining Report Completed Restorative Dining CNA
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+ PROGRESS NOTE
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Date/Time Progress Note Provider Day 364 Hosptice consult completed and hospice care initiated Hospice company Day 364 Resident satisfied with aspects of daily life, no issues Day shift nurse Day 363 Resident ate all food provided at evening meal, slept uninterrupted Night shift nurse Day 363 Satisfied with life, no problems, supplements not consumed Day shift nurse Day 364 Checked on resident. Sleeping well, breathing normally. No issues or questions Night shift nurse Day 364 Resident still enjoys activities Day shift nurse Day 363 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 363 Resident comfortable with living arrangements Day shift, Director Of Nursing (DON) Day 363 Checked resident. Eyes closed, breathing normally. No problems Night shift nurse Day 362 No questions, resident responding slowly to conversational cues Day shift nurse Day 362 Checked on resident. Slept most of night, awake once, checked later--eyes closed, breathing normally. No problems Night shift nurse Day 361 Resident questions about visitors answered, no issues Day shift nurse Day 361 Checked on resident. Sleeping peacefully, breathing normally. No problems Night shift nurse Day 360 Resident satisfied, no problems Day shift nurse Day 360 Checked on resident. Sleeping, breathing normally. No issues Night shift nurse Day 359 Restorative Dining Report Completed Day 359 Resident eating very little, satisfied, no problems Day shift nurse Day 359 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 358 Resident has no issues or questions Day shift nurse Day 358 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 357 Resident routine being followed Day shift nurse Day 357 Resident consumed supplements, sleeping well, breathing normally Night shift nurse Day 356 Resident happy with daily routine, no questions Day shift nurse Day 356 Sleeping well, eyes closed, breathing Night shift nurse Day 354 Resident Day shift nurse Day 354 Checked on resident. Eyes closed, breathing normally. No problems Night shift staff Day 354 Resident routine reviewed, satisfied with facility and services, questions answered Day shift, Director Of Nursing (DON) Day 354 Resident follows routine, Day shift nurse Day 353 Checked on resident. Eyes closed, breathing normally. No problems Night shift nurse Day 353 Resident routine going well, no problems Day shift Day 352 Checked on resident. Eyes closed, breathing normally. No problems Night shift Day 352 Resident satisfied with everything, no issues Day shift Day 351 Sleeping well, eyes closed, breathing Night shift Day 351 Resident cooperative Day shift Day 350 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 ACTIVITIES)
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+ HOSPICE CARE
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Each faciilty and hospice care organization has their own forms and documentation. In this facility the hospice documentation includes:
Type of Information Notification of Hospice Acceptance Date Facility Visit Note
Hospice Services Eligible Note
Patient Information Sheet (Note: Hospice calls them patients)
Upon Acceptance - Initial Forms Patient Bill of Rights - Hospice
Release Forms for information, insurance & financial responsibility
Benefit Election Form
Authorization to disclose personal information
Attending physician notification
Hospice Medicare/Medicaid Election
Hospice Routine Visit Notes (written by specific Hospice employees) Hospice Care Plan
Daily Notes
Weekly Notes
Monthly Notes
Quarterly Summary Notes
Communication Forms from Hospice RN to Facility RN/physician
Rectification Visit Notes