Use proper spelling and grammar.
Patient’s Name
Birth Date Age
Street Address
Phone Number
Hospital Number
Sex Marital Status State Zip County
City
Patient’s Occupation
Soc. Sec. #
Name
Address
Relationship
Phone No.
Responsible for Account
Religion
Date Admitted Time AM PM
Date Discharged Time AM PM
Date of Last Admission Name & Address of Any Institution From Which Discharged in Last 60 Days
Admitting Physician
Aitemding Physician
Consultant
Sundance HealthCare SystemsSundance HealthCare SystemsSundance HealthCare SystemsSundance HealthCare SystemsSundance HealthCare Systems Painted Valley, USAPainted Valley, USAPainted Valley, USAPainted Valley, USAPainted Valley, USA
Notify In Emergency
Room
Race
Ethnicity
Admitting Diagnosis (Within 24 Hours) ICD-9-CM CODESICD-9-CM CODESICD-9-CM CODESICD-9-CM CODESICD-9-CM CODES
Principal Diagnosis
Secondary Diagnoses
Complications
Operative Procedures (Date & Title)
Discharged Alive ____ Died ____ Autopsy Yes ____ No ____
Physician Signature
This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental. © 2003. American Health Information Management Association. All rights reserved.
ADMISSION SUMMARY SHEET
�������� �� �����
�
Congestive heart failure, left pleural effusion, pneumonia.
Dr. Archibald M. Graham
Dr. Archibald M. Graham
6/13/xx 1415 6/18/xx 1025
05/22/xx N/A
Jade Dare Daughter Self
2102 Fillmore Los Angeles 538 322-7734
101-87-3546 Taoism Asian
Retired Non-Hispanic
Dare, Jane V. 8032 Hao Jung Street # 822999
10/31/xx 73 San Francisco 823 762-3673
F Married California 85321-9626 Calaveras 773
Congestive heart failure, left pleural effusion, pneumonia.
CONDITIONS OF ADMISSIONCONDITIONS OF ADMISSIONCONDITIONS OF ADMISSIONCONDITIONS OF ADMISSIONCONDITIONS OF ADMISSION
1. CONSENT TO HOSPITAL CARE I am presenting myself for admission to Sundance HealthCare Systems. I voluntarily consent to the rendering of medical care which is determined to be necessary or beneficial in the professional judgement of my physician. This includes routine diagnostic procedures and medical treatment by authorized agents and employees of the Hospital, and by its medical staff, or their designees.
I acknowledge that no guarantees have been made to me as to the effect of such examination or treatment on my condition.
2. AUTHORIZATION TO RELEASE INFORMATION I authorize Sundance HealthCare Systems to release such information from my medical record as may be necessary for the completion of the hospital’s or my physician’s claims for reimbursement to my insurance company or agency. I UNDERSTAND THAT DISCLOSURE MAY INCLUDE DIAGNOSES AND OPERATIONS OR PROCEDURES PER- FORMED AND THAT, AT THE REQUEST OF MY INSURANCE COMPANY OR AGENCY, MY COMPLETE MEDI- CAL RECORD MAY BE SUBJECT TO REVIEW. IN ADDITION, I UNDERSTAND THAT COPIES OF MY RECORD MAY BE OBTAINED BY MY INSURANCE COMPANY OR AGENCY.
3. ASSIGNMENT OF BENEFITS In consideration of the services received or to be received for this admission to Sundance HealthCare Systems, I assign all insurance benefits due me. I further warrant that the hospital shall be entitled to the full amount of its charges. Any credit balance resulting for any reason will be applied to other existing accounts. This also assigns benefits to Anesthesia Consultants, PC.
I hereby agree to pay any and all hospital charges that exceed or that are not covered by my hospitalization insur- ance coverage. This assignment shall be irrevocable.
4. VALUABLES DISCLAIMER I understand that Sundance HealthCare Systems maintains a safe for the safekeeping of money and valuables. I, also, understand that I assume full responsibility for any and all of my valuables, money, clothing, dentures, and other personal items while a patient in the hospital unless deposited with the Hospital for safekeeping.
Valuables Deposited with the Hospital YES NO
5. REQUEST FOR FACILITY ACCOMMODATIONS I agree to pay to the Hospital any difference between the semi-private rate provided by my hospitalization insurance and the Hospital charges for a private accommodation. I understand that private accommodations are more expen- sive than the room rate payable by my hospitalization insurance and that it is my responsibility to pay the difference.
I request a Private Room YES NO
This document has been fully explained to me, and I certify that I understand its contents and agree to it freely.
AM DATE TIME PM Patient or authorized person
Witness Relationship
Guarantor/Insured Certificate Holder
Signature is not that of the patient because: ( ) patient is a minor
( ) other reason (specify):
6/13/xx 1415 ���������� �
��������� ��
�
�
Patient’s Name
Birth Date Age
Street Address
Phone Number
Hospital Number
Sex Marital Status State Zip County
City
Patient’s Occupation
Soc. Sec. #
Name
Address
Relationship
Phone No.
Responsible for Account
Religion
Date Admitted Time AM PM
Date Discharged Time AM PM
Date of Last Admission Name & Address of Any Institution From Which Discharged in Last 60 Days
Admitting Physician
Aitemding Physician
Consultant
Sundance HealthCare SystemsSundance HealthCare SystemsSundance HealthCare SystemsSundance HealthCare SystemsSundance HealthCare Systems Painted Valley, USAPainted Valley, USAPainted Valley, USAPainted Valley, USAPainted Valley, USA
Notify In Emergency
Room
Race
Ethnicity
Admitting Diagnosis (Within 24 Hours) ICD-9-CM CODESICD-9-CM CODESICD-9-CM CODESICD-9-CM CODESICD-9-CM CODES
Principal Diagnosis
Secondary Diagnoses
Complications
Operative Procedures (Date & Title)
Discharged Alive ____ Died ____ Autopsy Yes ____ No ____
Physician Signature
This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental. © 2003. American Health Information Management Association. All rights reserved.
ADMISSION SUMMARY SHEET
Sundance HealthCare Systems Painted Valley, USA
Form 9427 (8/00) mr HISTORY & PHYSICAL
Signature Dr.
Simulated record. © 2003. American Health Information Management Association. All rights reserved.
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
This 73-year-old female presents to ER C/O of SOB x 3-4 days. Not sleeping well. Increase pedal edema. Denies cough or fever. Has history of atrial fibrillation severe regurgitation from tricuspid and mitral valve dysfunction.
Allergy: Sulfa
Medications: 1. Capoten 25 mg po tid 2. Furosemide 40 mg po qd 3. Digoxin 0.125 mg po qod 4. Nortriptyline HCL 10 mg po qhs 5. Tylenol 325 mg tabs prn for pain 6. KLOR 10 mg qd 7. Milk of Magnesia 30 cc po qd prn
Family History: Noncontributory.
Social History: Has been living with husband. Negative for alcohol. Ex-smoker for many years.
PHYSICAL EXAMINATION: Pleasant, sitting upright. HEENT: Difficult fundoscopic exam. Neck: Supple with positive venous distension CNS: Rate 104, irregular with gallop. Crackles in left lower lobe. Right is dull. Abdomen: Benign. Genitalia: Normal except for red sacral area. No obvious breakdown. Extremities: 3+ pitting edema to knees. Neurological: Appropriate. Alert.
Chest x-ray: Left pleural effusion, congestive heart failure, pneumonia.
Assessment: Congestive heart failure, left pleural effusion, pneumonia.
Sundance HealthCare Systems Painted Valley, USA
Form 9427 (8/00) mr HISTORY & PHYSICAL
Signature Dr.
Simulated record. © 2003. American Health Information Management Association. All rights reserved.
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
Plan: Admit. Diurese IV antibiotics Blood cultures and sputum if possible O2 Bedrest
�������� �� �����
To Be Completed Upon Transfer: Date: _____/_____/_____ Time: ____:____ Transferred From: ________________________________________ Reason for Transfer: ________________________________________
Transferred Via: � Ambulance � Paramedics � Police � Fire
� Relative � O t h e r : _________________________________ Diagnoses on Principal Transfer Secondary
Form 3734 (4/02) nsg
Sundance HealthCare Systems Painted Valley, USA
���������� � ��� ����� ��� � ���
Transfer Form
Transfer Data: Report Author Date
Face Sheet
Discharge Summary
History and Physical Exam
Consultation(s)
Ancillary Department(s)
Immunizations
� Pneumovax � Flu
� Tetanus _____
Self-Cares
Bathes Self � Yes � No
Washes Face/Hands � Yes �No
Oral Care/Self � Yes � No
Combs Hair � Yes � No
Shaves Self � Yes � No
Dresses Self � Yes � No
Transfers Self � Yes � No
Walks Self � Yes � No
Feeds Self � Yes � No
Restraints � Yes � No
Side Rails � Yes � No
Dietary
Diet � Unrestricted � Low Salt
� Diabetic _____ # Calories
� Low Residue � Bland
Nursing Summary
Transfer Data: Report Author Date
Imaging
EKG/Cardio
CBC
Urinalysis
Other Lab
Personal Property/Assistive Devices
Patient has: Corrective Lenses: � Glasses Sent with Patient � Yes � No � Contacts � Yes � No
� Reading Glasses Only � Yes � No
Dentures � Upper � Full � Partial � Yes � No � Lower � Full � Partial � Yes � No
Hearing Aids � Right � Left � Yes � No Assist Devices � Walker � Cane � Reacher � Yes � No
Advanced Directives:
Patient has: Living Will: � Yes � No Location: _____________________ Power of Attorney: � Yes � No Location: _____________________ Code Level: ____________________ Executor: _____________________
6 18 xx 10 25 Sundance HealthCare Systems Need for continued skilled nursing care
�
CHF, left pleural effusion and pneumonia
� Hospital Record �
None None Named
� �
� � �
� � � � �
�
� �
� �
� �
� �
� �
� �
Patient is very unhappy due to fact she has been separated from her husband. Presently still in need of help with ADLs, experiences periods of SOB upon minimal exertion. It is anticipated that the patient will be able to return to her home with home health care support. Continue with physical therapy and occupational therapy.
Dare, Jane Dr. Archibald M. Graham Room 773
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
SOCIAL SERVICES SCREENING
___ Bill of Rights reviewed with resident or _______________________.
___ Care Conference Process. To be included: _____________________.
___ Policy regarding bedholds during hospitalizations.
___ Information regarding state law on Advance Directives.
___ Durable Power of Attorney.
___ Grievance Policy and Procedure.
___ Primary contact person: ________________________________________
Secondary contact person: ______________________________________
Guardianship or P-O-A document located at _____________________________
____ Financial assistance. If requested, referred to ______________________.
Date: _________ By: _______________________________________
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
Simulated record. © 2003. American Health Information Management Association. All rights reserved.
�
�
�
�
�
�
� Jade Dare
�
6/13/xx �������� ������ �����
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
Sundance Medical Center Painted Valley, USA
Simulated record. © 2003. American Health Information Management Association. All rights reserved.
RESIDENT ASSESSMENT PROTOCOL
Document problems, complications, and risks factors; the need for referral to appropriate health professionals; and the reason for deciding to proceed or not to proceed to care planning.
RAP Problem Area # 1
Delirium:
Resident triggers delirium because of deterioration of cognitive skills and deterioration of communica- tions skills. Causal factor of the RAP appears to be her cardiac diagnosis. She also appears to be depressed and very unhappy.
Will be seen by Dr. Archibald M. Graham on nursing home rounds.
Based on above documentation, will proceed with care planning.
����������� �� ������
RAP Problem Area # 2
Cognitive Loss/ Dementia:
Resident triggers cognitive loss/dementia because of mild, short term memory loss (forgetful) and some decision making problems. She is alert and oriented, but sometimes will forget the time or wonder why she is here. She has been complaining since admission regarding her room (too small, too humid, too hot, etc.) She swears at the staff and other residents. She cries easily.
Factor of triggered RAP appears to be sadness, unhappiness over being away from her husband. She had no diagnosis of dementia at this time.
Will be seen by Dr. Archibald M. Graham on nursing home rounds.
Based on above documentation, will proceed with care planning.
����������� �� ������
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
Sundance Medical Center Painted Valley, USA
Simulated record. © 2003. American Health Information Management Association. All rights reserved.
RAP Problem Area # 3
Nutritional Status:
Resident is on a NAS diet and has several food complaints/dislikes. Causal factors appears to be diagnosis of CHF.
Registered Dietitian will follow.
Proceed with care planning.
����������� �� ������
RAP Problem Area # 4
Communication:
Resident has mild impairment with cognitive skills for daily decision making. She often refuses to sleep in her room. States the room is too hot, too cold, too humid, too small, etc. Staff have found her sleeping on the floor of the guest room, sleeping in a chair in the guest room, etc. She make her needs known to staff. Has tried to refuse meds, and ADL assistance.
Will be seen by Dr. Archibald M. Graham on nursing home rounds.
����������� �� ������
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
Sundance Medical Center Painted Valley, USA
Simulated record. © 2003. American Health Information Management Association. All rights reserved.
RAP # 5
ADL Functions/Rehabilitation Potential:
Resident has self care deficit. She needs physical assist of 1 staff with dressing and bathing. She receives physical assistance of 1 to transfer at least q. d. She has been incontinent of BM almost q.d. Staff assists to bathroom and on and off toilet. She is too weak and SOB to be completely independent at this time. Causal factor appears to be end-stage cardiomyopathy.
Resident will be seen by Dr. Archibald M. Graham on nursing home rounds.
Based on the above documentation, will proceed to care planning.
����������� �� ������
RAP # 6
Mood State:
Resident is very unhappy here. Cries often “I want to go home”. States that she can’t make it another day without her husband. Many complaints about the staff, food, other residents, etc.
Causal factor appears to be sadness due to being apart from her husband.
Resident will be seen by Dr. Archibald M. Graham at nursing home rounds.
Based on above documentation, will proceed with care planning.
����������� �� ������
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
Sundance Medical Center Painted Valley, USA
Simulated record. © 2003. American Health Information Management Association. All rights reserved.
RAP # 7
Behavior Problems
Resident is unhappy with nursing home placement. Has many complaints, such as the room is unfit to live in, staff are no good, and the food is not good. Swears at the staff and other residents. The resident has actually hit staff members and refuses to sleep in her room.
Causal factor appears to be anger/adjustment problems. She has severe end-stage cardiomyopathy. Family states that she has been this way all her life.
Resident will be seen by Dr. Archibald M.Graham at nursing home rounds.
Based on above documentation, will proceed with care planning.
����������� �� ������
RAP # 8
Falls: Resident is at risk for falls based on the fact that she takes psychotropic medications. She has not fallen since she has been here. She needs assistance of 1 to transfer and ambulate. In the wheelchair she must be pushed to and from all locations as she becomes SOB if doing it herself. No restraints are being used. No complaints of vertigo, etc.
Causal factors appear to be triggered by psychotropic drug usage.
Based on above documentation, will proceed with care planning.
����������� �� ������
Sundance Medical Center Painted Valley, USA
����� ���� �� �
Physician Orders and Progress NotesForm # _ _ _ _
�� ���������
Simulated record. © 2003. American Health Information Management Association. All rights reserved.
Dare, Jane Dr. Archibald M. Graham Room 773
# 822999
6/13/xx
Admit to room 773.
Primary Diagnosis: Congestive heart failure, severe
end stage ischemic cardiomyopathy.
Allergy: Sulfa
PT: Evaluate and gait training ambulation with
appropriate assistance device. Utilizes front wheeled
walker with assistance of 1-2. Strength training, bed
mobility and transfer training. Rehab potential fair.
Medications: Capoten 25 mg po tid
Furosemide 40 mg po qd
Nortriptyline HCL 10 mg po qd
Digoxin 0.125 mg po qod
Diet: Low sodium, low cholesterol. Lactose
intolerance. No dairy products.
�������� �� �����
6/13/xx Two step Mantoux
Standing orders
VO Dr. Archibald M. Graham / ������������ � �
�������� �� �����
6/13/xx Standing Orders for Area Nursing Facility Residents
To The Physician: Please draw a RED LINE Through
orders you DO NOT WISH resident to receive. All
other orders may be implemented by the nurse at the
time without contacting the physician.
At the time of implementation of a standing order, the
nurse may record the order on the physician order
sheet and transcribe it in the appropriate manner.
�������� �� �����
jA
Sundance Medical Center Painted Valley, USA
����� ���� �� �
Physician Orders and Progress NotesForm # _ _ _ _
�� ���������
Simulated record. © 2003. American Health Information Management Association. All rights reserved.
Dare, Jane Dr. Archibald M. Graham Room 773
# 822999
6/13/xx
1. ACHING/FEVER: Acetaminophen 650 mg. po
prn /fever > 100 po or tympanic 101 rectal.
2. BOWEL MANAGEMENT:
a. MOM 30 cc po q.d. prn
b. Fleets Enema ® q.d. prn
3. CATHETERIZATION:
a. Straight catheterize prn for UA
b. Straight catheterize prn inability to void: notify
MD within 24 hours
4. CERUMEN: Ear wax removal per facility protocol.
5. COUGH: Guaifenesin (pharmacy stock) 10 cc po
q.4h. p.r.n.
6. DRY AND/OR IRRITATED EYES: Methyicellulose
(pharmacy stock) eye drop to affected eye(s)
q.4h. prn.
7. DIARRHEAL: Kaopectate Concentrate 2
tablespoons after each loose stool prn not to exceed
7 doses in a 24 our period.
8. DYSPNEA: Oxygen 2 liters/min prn nasal cannula:
contact physician for order if mask is indicated.
9. GI DISTRESS: Antacid (pharmacy stock) 1
teaspoon po q4h prn.
10. IMMUNIZATION: Influenza vaccine 0.5 mg (IM)
X 1 dose annually.
Diphtheria and tetanus (IM) according to facility
policy.
a. If a resident has never received a Diphthia/
Tetanus series, give:
1.0.5 cc D/T initially
2.0.5 cc DT 4-8 weeks later
3.0.5 cc DP 6 months later
b. If a booster is needed, give adult Diphtheria/
Tetanus 0.5 cc
�������� �� �����
Sundance Medical Center Painted Valley, USA
����� ���� �� �
Physician Orders and Progress NotesForm # _ _ _ _
�� ���������
Simulated record. © 2003. American Health Information Management Association. All rights reserved.
Dare, Jane Dr. Archibald M. Graham Room 773
# 822999
6/13/xx continued
c. Repeat booster every 10 years.
11. LAB WORK, PRN
a. Culture Specimen for culture and sensitivity of
any purulent wound/skin drainage.
b. tract infection suspect:
c. Dipstrick for leukocytes and nitrates prn
symptoms or UTI. Call MD for orders if results
positive.
d. Or UA if symptomatic
12. REHABILITATION SERVICES (PT. OT.
SPEECH): Screen/evaluate and treat as indicated.
13. SKIN BREAKDOWN:
a. Cleanse open areas with normal saline daily and
leave open to air.
b. Transparent dressing to open areas until healed.
Change prn.
c. Hydroactive dressing to pressure ulcer until
healed. Change prn.
d. Steri-strips prn minor lacerations.
14. THERAPEUTIC LOA: May go on therapeutic leave
of absence with current meds according to facility
policy.
15. TUBE FEEDING: Replace N/G or G-tube prn.
�������� �� �����
Sundance Medical Center Painted Valley, USA
����� ���� �� �
Physician Orders and Progress NotesForm # _ _ _ _
�� ���������
Simulated record. © 2003. American Health Information Management Association. All rights reserved.
Dare, Jane Dr. Archibald M. Graham Room 773
# 822999
I AUTHORIZE THE NURSING STAFF TO
INITIATE ANY OF THE ABOVE ORDERS AT
ANY TIME DURING THIS RESIDENT’S STAY
WITHOUT NOTIFYING ME. ANY ORDER NOT
USED FOR 30 DAYS MAY BE DROPPED FROM
CURRENT ORDERS AND RESTARTED AT ANY
TIME WITHOUT NOTIFYING ME.
6/13/xx �������� �� �����
6/14/xx OT for Strengthening, endurance building and
ADL training.
TO Dr. Archibald M. Graham / ������������ � �
�������� �� �����
6/18/xx Okay for patient to transfer to St. Mary’s Care Center
for continued skilled nursing care.
TO Dr. Archibald M. Graham / ������������ � �
�������� �� �����
Sundance Medical Center Painted Valley, USA
����� ���� ��� ����������� ����
�������� � ������� ��� Simulated record. © 2003. American Health Information Management Association. All rights reserved.
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
6/13/xx Admitted via wheelchair from the hospital unit. Frail appearing Asian female. Is very pleasant
2:00 p.m and answers questions appropriately. Code level discussed with patient and husband on
telephone. A decision was made for no CPR.
����������� �� ������
6:00 p.m T 99.5, R 64, P 24, BP 112/62. Sitting out in dining room waiting for supper. Went to
activities earlier this afternoon. No complaints.
������� ��� � ��� �
10:00pm T 99, R 72, P 20, BP 108/56. In wheelchair visiting with another resident in the library earlier.
Now refusing to sleep in her room. States the room is too small and she feels like she can’t
breathe when she is in there. Wants to sit in the recliner near the nurse’s station for now.
Margie Cutler, RN
11:00 p.m Has been dozing in the recliner. Now is awake and requesting to go to the bathroom.
Assisted to the bedroom in her room. Voided a large amount and had a moderate small
brown bowel movement. Still refuses to stay in her room.
Margie Cutler, RN
6/14/xx
2:00 a.m T 98.2, R 80, P22, BP 108/62 Has been dozing while reclined in the recliner by the
nurses station.
������� ��� � ��� �
6:00 a.m Requested assistance to and from the bathroom. Voided and had a loose brown bowel
movement. Dozing in the recliner.
������� ��� � ��� �
10:00 a.m Upset and states that she wants two pills that she was given in the hospital for her loose
stools. Refused a.m. cares. Had a small soft stool without diarrhea.
����������� �� ������
Sundance Medical Center Painted Valley, USA
����� ���� ��� ����������� ����
�������� � ������� ��� Simulated record. © 2003. American Health Information Management Association. All rights reserved.
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
1:00 p.m Patient was evaluated and treated initially by Physical Therapy.
����������� �� ������
3:00 p.m Asked to speak with husband on the phone. Afterwards the patient stated that she does not
want to stay here because no one is caring for her. Husband called and spoke to the head
nurse. Husband was assured that Jane’s needs are being attended to.
����������� �� ������
4:30 p.m Social worker here to see patient.
Margie Cutler, RN
7:00 p.m Family came and brought the resident’s husband. He lives in their home about 30 miles away.
Patient would like to return home with her husband. Family is stressing the need to stay in this
facility for awhile until she gets stronger and can return to her home with home health support.
Margie Cutler, RN
10:00 p.m Appearing sleepy and wants to go to bed. Resident still does not want to sleep in her room.
States that it is too small but will try it tonight.
Margie Cutler, RN
6/15/xx
6:00am Appears to have slept all night. No complaints.
������� ��� � ��� �
10:00 am Resident was hit on the forehead by another resident. No break in skin, Resident states
head does not hurt and glasses were not hit. Calm and sitting in chair. Will continue to
observe for potential injury. BP 96/68, P116, R 24, PERL. Grasp equal and strong.
Denies any discomfort. States, “I’m not scared”.
����������� �� ������
Sundance Medical Center Painted Valley, USA
����� ���� ��� ����������� ����
�������� � ������� ��� Simulated record. © 2003. American Health Information Management Association. All rights reserved.
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
6/16/xx Resident is alert and oriented to self and family. Communicates needs with some difficulty.
11:14 a.m Becomes teary eyed when frustrated and then has difficulty in communicating needs. Needs
assistance with bath and shampoo. Able to brush own teeth.
����������� �� ������
1:23 p.m Resident is becoming very abusive to staff. Frequently hollers, “You’re stupid”. to anyone
who close by. Is able to feed self after the food has been cut-up and containers are opened
for her. Hollers throughout meals, “I don’t like that” and “This is not fit to eat.” Also has
been having weepy episodes and states, “I want to get out of here and go home”.
����������� �� ������
6/17/xx
10:05am Talked to son and a Care Conference is scheduled for tomorrow
����������� �� ������
2:35 p.m Resident is oriented to person, place and time. Verbal abuse is increasing to all staff and
other residents. Spends very little time in her room. States, “It is too small and cold. I
just can’t stay in there”.
����������� �� ������
6/18/xx 10:025am Patient prepared for discharge and transfer. Transfer to St. Mary’s Care Center
at Northwild per City Ambulance Service. Transfer sheet, medications, and personal articles
sent with resident.
����������� �� ������
Sundance Medical Center Painted Valley, USA
���������� � ��� ����� ��� � ��� ������
���������� ������� ���� ����� ����
Form 7734b (rev 6/03) MR ���������� ������� ���� Simulated record. © 2003. American Health Information Management Association. All rights reserved.
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
PT notes
6/14/x Initial treatment: Resident transferred well with minimal assistance. Independent bed mobility.
Strength is equal bilaterally. 4/5 hip musculature, 4/5 quads, 5/5 hamstrings, 4/5 ankle. Sitting
and standing balance is good. Ambulated 60’ with wheeled walker and minimal assistance of
one. Will see 5 times a week for exercise and gait training with goal of independence in
mobility.
�������� ��� ��������
Social worker notes
6/14/x Tried talking with patient when she was in her wheelchair by the nurses station. She was angry
and I was unable to have a conversation with her. A few minutes later she was in the dining
room and came with me into the library. Her mood had changed drastically and I was able to
review the Bill of Rights. Patient was pleasant but her answers were short phrases.
Patient would like to return to her home. Explained to patient that a decision was made with
her, her family and her physician to spend some time in this facility after her stay in the hospital.
The ultimate plan is for her return to her home to be with her husband. Son requests a Care
Conference and it is scheduled for 6/18/xx.
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OT notes
6/15/xx Resident is being seen for ADL training. She is alert and oriented. She states that her goal is
to return to previous living with her husband. Strength and endurance is poor. Functional skills
have decreased due to deceased strength and endurance.
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PT
6/16/xx Resident is independent in bed mobility. Transfers with standby assistance. Walks 50’ with
wheeled walker and stand-by assistance. Balance is good. Distance depends on whether she
is SOB. Was SOB today. Pulse was OK. States that the humidity makes breathing difficult.
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Sundance Medical Center Painted Valley, USA
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Form 7734b (rev 6/03) MR ���������� ������� ���� Simulated record. © 2003. American Health Information Management Association. All rights reserved.
Dare, Jane Dr. Archibald M. Graham Room 773 # 822999
OT notes
6/17/xx Jane has been pleasant and cooperative. Occasionally she has SOB and decreased
endurance due to high humidity weather. Overall demonstrates improving strength,
endurance and standing tolerance through increasing weights, repeated exercises, and
increasing standing time. Resident would benefit from continued occupational therapy.
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Care Conference 6/18/xx
Son states that his mother wants to be near his father who lives in Northwild, about 30 miles
away but his father would not be able to care for her and she is not yet a candidate for home
health. There is a long term care facility a short distance from their home with a current opening
at this time. The son believes that his mother would be much happier if a transfer could be
made as soon as possible. Arrangements will be made.
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6/18/xx Physical and Occupational Therapy Discharge Summary
Jane received physical and occupational therapy from the time she was admitted to our facility
through her discharge. She progressed from assistance of 1 with transfers and ambulation to
minimal assistance only. She is independent in bed mobility. Strength has improved, as has her
endurance. The resident can ambulate 100 to 150 feet with a wheeled walker. She can
ambulate without a walker, but gait pattern is poor. Her largest remaining problem is shortness
of breath, and this limits her activity level. We have been unable to have her become completely
independent of the wheelchair because of this.
Our recommendations are that Jane continue to ambulate at least 1 to 2 times/day, and
that she be encourage to participate in her cares as much as possible.
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Sundance HealthCare SystemsSundance HealthCare SystemsSundance HealthCare SystemsSundance HealthCare SystemsSundance HealthCare Systems Painted Valley, USAPainted Valley, USAPainted Valley, USAPainted Valley, USAPainted Valley, USA
NAME X-RAY NO.
DOCTOR DATE
REGION EXAMINED
M.D. RADIOLOGIST’S SIGNATURE
Simulated record. © 2003. American Health Information Management Association. All rights reserved.
Jane Dare 1223-14x
Who 6/13/xx Chest: PA and Lateral
Dare, Jane Dr. Who Room 773 # 822999
6/7/xx Chest: PA and Lateral
INDICATION: CHF, pleural effusion, pneumonia.
FINDINGS: PA and lateral chest compared with 6-7-xx. There has been slight improvement in the left lower lung field infiltrate. Small bilateral pleural fluid collections persist. Stable cardiac and mediastinal silhouettes.
CONCLUSION: Slight interval improvement of the appearance of the chest.
WCR/bca
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