The patient file contains several inaccuracies and inconsistencies. Using your knowledge of medical terminology, anatomy, and physiology,articulate three issues you’ve identified.b)Explain in detail what makes the identified issues a problem in terms of patient health and record keeping.

The patient file contains several inaccuracies and inconsistencies. Using your knowledge of medical terminology, anatomy, and physiology,articulate three issues you’ve identified.b)Explain in detail what makes the identified issues

a problem in terms of patient health and record keeping. Be sure to use appropriate medical terminology, references to anatomy, and concepts of normal physiology, where appropriate.c)Discuss the impact of the issues on the patient, the coding system, and the billing system if they had not been caught, using the appropriate terminology.d)Illustrate how you would work to address

each issue, with specific detail regarding who you would pull into the discussion and who would be

responsible for the particular details of each issue in a real medical setting.

1 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. Global Care Medical Center 100 Main St, Alfred NY 14802 (607) 555-1234 Hospital No. 999 INPATIENT FACE SHEET Patient Name and Address Gender Race Marital Status Patient No. PIRE, SALLY 1122 CHERRY STREET ALMOND, NY 14804 F W S IPCase006 Date of Birth Age Maiden Name Occupation 06/23/YYYY 60 NA Nurses’ Aide Admission Date Time Discharge Date Time Length of Stay Telephone Number 06-30-YYYY 12:45 07-07-YYYY 10:00 05 DAYS (607)000-4397 Guarantor Name and Address Next Of Kin Name and Address PIRE, SALLY 1122 CHERRY STREET ALMOND, NY 14804 PIRE, JACOB 556 MILL STREET ALMOND, NY 14804 Guarantor Telephone No. Relationship to Patient Next of Kin Telephone Number Relationship to Patient (607) 000-4397 Self (607)555-7676 BROTHER Admitting Physician Service Admit Type Room Number/Bed John Black, MD ME NA 0371 Attending Physician Admitting Diagnosis John Black, MD Bacterial pneumonia Primary Insurer Policy and Group Number Secondary Insurer Policy and Group Number New Age Insurance PW 6790456 NEBC 229162171 Diagnoses and Procedures ICD Code Principal Diagnosis Bacterial Pneumonia Secondary Diagnoses Arteriosclerotic cardiovascular disease Principal Procedure Secondary Procedures Discharge Instructions Activity:  Bed rest  Light  Usual  Unlimited Other: As tolerated. Diet:  Regular  Low Cholesterol  Low Salt  ADA  _____ Calorie Follow-Up: Call for appointment Office appointment on 07-14  Other: Special Instructions: Attending Physician Authentication: Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 06/30/YYYY 01:00:00 PM EST) 2 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 CONSENT TO ADMISSION I, Sally Pire hereby consent to admission to the Global Care Medical Center (ASMC) , and I further consent to such routine hospital care, diagnostic procedures, and medical treatment that the medical and professional staff of ASMC may deem necessary or advisable. I authorize the use of medical information obtained about me as specified above and the disclosure of such information to my referring physician(s). This form has been fully explained to me, and I understand its contents. I further understand that no guarantees have been made to me as to the results of treatments or examinations done at the ASMC. Reviewed and Approved: Sally Pire ATP-B-S:02:1001261385: Sally Pire (Signed: 06/30/YYYY 01:45:05 PM EST) Signature of Patient Signature of Parent/Legal Guardian for Minor Relationship to Minor Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 06/30/YYYY 01:45:05 PM EST) WITNESS: Global Care Medical Center Staff Member CONSENT TO RELEASE INFORMATION FOR REIMBURSEMENT PURPOSES In order to permit reimbursement, upon request, the Global Care Medical Center (ASMC) may disclose such treatment information pertaining to my hospitalization to any corporation, organization, or agent thereof, which is, or may be liable under contract to the ASMC or to me, or to any of my family members or other person, for payment of all or part of the ASMC’s charges for services rendered to me (e.g. the patient’s health insurance carrier). I understand that the purpose of any release of information is to facilitate reimbursement for services rendered. In addition, in the event that my health insurance program includes utilization review of services provided during this admission, I authorize ASMC to release information as is necessary to permit the review. This authorization will expire once the reimbursement for services rendered is complete. Reviewed and Approved: Sally Pire ATP-B-S:02:1001261385: Sally Pire (Signed: 06/30/YYYY 01:47:05 PM EST) Signature of Patient Signature of Parent/Legal Guardian for Minor Relationship to Minor Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 06/30/YYYY 01:48:05 PM EST) WITNESS: Global Care Medical Center Staff Member 3 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 ADVANCE DIRECTIVE Your answers to the following questions will assist your Physician and the Hospital to respect your wishes regarding your medical care. This information will become a part of your medical record. YES NO PATIENT’S INITIALS 1. Have you been provided with a copy of the information called “Patient Rights Regarding Health Care Decision?” X 2. Have you prepared a “Living Will?” If yes, please provide the Hospital with a copy for your medical record. X 3. Have you prepared a Durable Power of Attorney for Health Care? If yes, please provide the Hospital with a copy for your medical record. X 4. Have you provided this facility with an Advance Directive on a prior admission and is it still in effect? If yes, Admitting Office to contact Medical Records to obtain a copy for the medical record. X 5. Do you desire to execute a Living Will/Durable Power of Attorney? If yes, refer to in order: a. Physician b. Social Service c. Volunteer Service X HOSPITAL STAFF DIRECTIONS: Check when each step is completed. 1.  Verify the above questions where answered and actions taken where required. 2.  If the “Patient Rights” information was provided to someone other than the patient, state reason: Name of Individual Receiving Information Relationship to Patient 3.  If information was provided in a language other than English, specify language and method. 4.  Verify patient was advised on how to obtain additional information on Advance Directives. 5.  Verify the Patient/Family Member/Legal Representative was asked to provide the Hospital with a copy of the Advanced Directive which will be retained in the medical record. File this form in the medical record, and give a copy to the patient. Name of Patient Name of Individual giving information if different from Patient Reviewed and Approved: Sally Pire ATP-B-S:02:1001261385: Sally Pire (Signed: 06/30/YYYY 01:48:05 PM EST) Signature of Patient Date Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 06/30/YYYY 01:49:05 PM EST) 4 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. Signature of Hospital Representative Date GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 PATIENT HISTORY PROBLEMS: 1. Arteriosclerotic cardiovascular disease; 2. Past history of alcoholism; 3. Past history of hypokalemia; 4. Past history of gastritis. MEDICATIONS: Lanoxin 0.125 milligrams a day Lasix 20 milligrams a day Klotrix tablets 1 tablet three times daily PAST MEDICAL HISTORY: Patient has had some problems with alcohol in the past and a history of gastritis due to excessive alcohol intake. She had a fractured wrist last year potentially a secondary injury due to excessive inebriation. She also has recently been put on Lanoxin and Lasix, apparently for arteriosclerotic cardiovascular problems, as she experienced mild angina. Subsequent to her second admission in YYYY, she was referred to General Hospital for further evaluation and treatment of her abnormal liver function studies. It was determined at that time that she did not have an active process. ALLERGY TO ASPIRIN FAMILY HISTORY: History of alcoholism on mother’s side and cardiovascular disease on father’s side. Brother has had heart attack related to coronary artery disease. SOCIAL HISTORY: She works as a nurse’s aide. She’s a moderate smoker. Denies heavy drinking, but we are not quite sure about that. DD: 06/30/YYYY Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 06/30/YYYY 06:05:44 PM EST) DT: 07/01/YYYY Physician Name 5 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 DISCHARGE SUMMARY ADMISSION DATE: 06/30/YYYY DISCHARGE DATE: 07/07/YYYY ADMISSION DIAGNOSIS: 1. Viral pneumonia; 2. Arteriosclerotic cardiovascular disease; 3. Past history of alcoholism; 4. Past history of hypokalemia; 5. Past history of gastritis. DISCHARGE DIAGNOSES: Pneumonia. Arteriosclerotic cardiovascular disease. SUMMARY: This is a 61-year-old white female who has been doing fairly well recently until the onset of an upper respiratory infection with a cough, recurrent chills, sweats, fever. She tried to work, was unable to. Her temperature went to 102. Abdominal x-ray showed a pneumonia, and I felt that she should be admitted for further evaluation and treatment. Work-up has included a chest x-ray which revealed a small area of infiltrate in the lingular of the right side compatible with an acute pneumonia; a follow-up study is suggested. Repeat chest x-ray showed bilateral pneumonia, clearing; however, there was a remaining area of consolidation in the lateral portion of the middle lobe. Her urine showed a specific gravity of 1.015, albumin and sugar were negative, white blood cells rare, red blood cells 0-6. White count 15,000. Hemoglobin 11.8, hematocrit 34.8, segmented cells 52, lymphocytes 18, monocytes 12, eosinophils 3, and 5 band cells. Complete blood count was normal. Sodium 137, potassium 3.4, carbon dioxide 27, chloride 97, alkaline phosphatase 10.4, blood sugar 81, cholesterol 138, Serum glutamic oxalacetic transaminase 42, Lactate dehydrogenase 260, creatinine 0.4, calcium 8.3, phosphorus 2.2, bilirubin 1.2, total protein 6.1, albumin 3.2, uric acid 0.5. Sputum culture grew out a 1+ enterobacter. Cardiogram was reported as showing sinus tachycardia; this later slowed down clinically. She was started originally on Ampicillin 500 milligrams, four times a day, Intermittent positive pressure breathing. She was continued on her Lanoxin 0.125 a day, Lasix 20 milligrams a day, Klotrix tablets 1 tablet three times a day. Her temperature stayed up, her Ampicillin was stopped, and she was switched to Enalapril 500 milligrams, four times a day. Now her temperature has been normal for 48 hours. She feels better, and her cough has lessened. She is up ambulatory, and she is anxious to go home. She is being discharged at this time on E-Mycin 333 milligrams, three times a day and Afrin nasal spray. She will continue on her Lanoxin 0.125 milligrams a day, Lasix 20 milligrams a day, and should be seen in follow-up in the office early next week. DD: 06/30YYYY Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 06/30/YYYY 05:44:18 PM EST) DT: 07/01/YYYY Physician Name GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 6 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 CURRENT VISIT & PHYSICAL EXAM ADMISSION DIAGNOSIS: 1. Bacterial pneumonia; 2. Arteriosclerotic cardiovascular disease; 3. Past history of alcoholism; 4. Past history of hypokalemia; 5. Past history of gastritis. CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: This is a 60-year-old female who has been in the hospital on two occasions within the past year or two. Her last admission was related to some problems with alcohol. Prior to that she had been in with some abnormal liver function studies that were later evaluated at Strong. Recently she’s been doing fairly well until a few days ago when she had the onset of upper respiratory symptoms. She continued to work. She now is coughing, having chills, fever, and sweats. She was seen and evaluated in the office this morning. She had fever of 102. We referred her over for a chest x-ray which showed pneumonia of the left lung field, and she subsequently was admitted for further investigation, evaluation, and treatment. FAMILY HISTORY: History of alcoholism on mother’s side and cardiovascular disease on father’s side. Brother has had heart attack related to coronary artery disease. SOCIAL HISTORY: She works as a nurse’s aide. She’s a moderate smoker. Denies heavy drinking, but we are not quite sure about that. REVIEW OF SYSTEMS: She has hacking cough, slight dyspnea on exertion, 2 pillow orthopnea, no hemoptysis. Appetite has been fair. She denies any specific bowel or bladder symptomatology. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 102. Pulse 90, Respirations 24. SKIN: Warm, dry. EYES: pupils round, reactive and equal. Extraocular muscles intact. Sclera clear; no evidence of any jaundice. Nose and throat are unremarkable. NECK: Supple. No nodes or thyroid abnormalities. CHEST: Scattered rales and rhonchi at both mid-lung fields. HEART: Sounds are somewhat distant. No significant murmurs are heard. BREASTS: Soft and free of masses. ABDOMEN: No palpable organomegaly or masses. No tenderness or bruits. Bowel sounds normally active. PELVIC: Not done. RECTAL: Not done. EXTREMITIES: Warm, pulses good. NEUROLOGIC: Okay. DD: 06/30/YYYY Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 06/30/YYYY 06:05:44 PM EST) DT: 07/01/YYYY Physician Name GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 7 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 PROGRESS NOTES Date Time Physician’s signature required for each order. (Please skip one line between dates.) 06/30/YYYY 1300 CHIEF COMPLAINT: Shortness of breath. DIAGNOSIS: 1) Pneumonia. 2) Arteriosclerotic cardiovascular disease. Confirmed _______ Provisional __X___ PLAN OF TREATMENT: Admit for evaluation and treatment. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 06/30/YYYY 01:47:02 PM EST) 06/30/YYYY 1800 Intermittent positive pressure breathing ordered four times a day and saline for 48 hours. Started at 1730. Patient tolerated well. Slight production with cough, sputum clear in color. Reviewed and Approved: Rose Markam, CPT ATP-B-S:02:1001261385: Rose Markam, CPT (Signed: 06/30/YYYY 06:07:22 PM EST) 07/01/YYYY 0800 Intermittent positive pressure breathing treatment given at 0700. Non-productive cough noted. Reviewed and Approved: Shelly White CPT ATP-B-S:02:1001261385: Shelly White CPT (Signed: 07/01/YYYY 08:17:30 AM EST) 07/01/YYYY 1000 Intermittent positive pressure breathing treatment given at 1000. Tolerated well. Reviewed and Approved: Shelly White CPT ATP-B-S:02:1001261385: Shelly White CPT (Signed: 07/01/YYYY 10:06:00 AM EST) 07/01/YYYY 1300 Intermittent positive pressure breathing treatment given at 1300. Good treatment. Reviewed and Approved: Shelly White CPT ATP-B-S:02:1001261385: Shelly White CPT (Signed: 07/01/YYYY 01:17:30 PM EST) 8 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802  (607) 555-1234 9 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 PROGRESS NOTES Date Time Physician’s signature required for each order. (Please skip one line between dates.) 07/01/YYYY 1600 Intermittent positive pressure breathing treatment given at 1600. Tolerated well. Reviewed and Approved: Rose Markam, CPT ATP-B-S:02:1001261385: Rose Markam, CPT (Signed: 07/01/YYYY 04:10:30 PM EST) 07/01/YYYY 1900 Still feels “lousy.” Temperature up. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/01/YYYY 07:07:42 PM EST) 07/02/YYYY 1000 Intermittent positive pressure breathing treatment not given at 0700. Therapist busy in Intensive Care Unit. 1000 tolerated. Reviewed and Approved: Shelly White CPT ATP-B-S:02:1001261385: Shelly White CPT (Signed: 07/02/YYYY 10:06:00 AM EST) 07/02/YYYY 1300 Intermittent positive pressure breathing treatment given. Some production. Reviewed and Approved: Shelly White CPT ATP-B-S:02:1001261385: Shelly White CPT (Signed: 07/02/YYYY 01:17:30 PM EST) 07/02/YYYY 1600 Intermittent positive pressure breathing treatment given at 1600. Tolerated. Reviewed and Approved: Rose Markam, CPT ATP-B-S:02:1001261385: Rose Markam, CPT (Signed: 07/02/YYYY 04:06:00 PM EST) 07/02/YYYY 1900 Hydration good. Not much appetite. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/02/YYYY 07:07:42 PM EST) 07/03/YYYY 0800 Temperature still up. Will switch to Erythromycin. Still ambulatory as tolerated. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/03/YYYY 08:07:42 AM EST) 10 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802  (607) 555-1234 PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 PROGRESS NOTES Date Time Physician’s signature required for each order. (Please skip one line between dates.) 07/03/YYYY 1030 Intermittent positive pressure breathing treatment with normal saline four times a day for 48 hours started at 1030. Tolerated well. No cough noted. Reviewed and Approved: Shelly White CPT ATP-B-S:02:1001261385: Shelly White CPT (Signed: 07/03/YYYY 10:36:00 AM EST) 07/03/YYYY 1300 Intermittent positive pressure breathing treatment at 1300. Tolerated well. Reviewed and Approved: Shelly White CPT ATP-B-S:02:1001261385: Shelly White CPT (Signed: 07/03/YYYY 01:06:45 PM EST) 07/03/YYYY 1700 Intermittent positive pressure breathing treatment at 1700. Tolerated well. Reviewed and Approved: Rose Markam, CPT ATP-B-S:02:1001261385: Rose Markam, CPT (Signed: 07/03/YYYY 05:03:00 PM EST) 07/04/YYYY 0700 Feels better. Temperature coming down. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/04/YYYY 07:02:30 AM EST) 07/04/YYYY 0700 Intermittent positive pressure breathing treatment at 0700. Tolerated well. No cough. Reviewed and Approved: Shelly White CPT ATP-B-S:02:1001261385: Shelly White CPT (Signed: 07/04/YYYY 07:06:45 AM EST) 07/04/YYYY 1000 Intermittent positive pressure breathing treatment at 1000. Tolerated. Reviewed and Approved: Shelly White CPT ATP-B-S:02:1001261385: Shelly White CPT (Signed: 07/04/YYYY 10:02:17 AM EST) 07/04/YYYY 1300 Intermittent positive pressure breathing treatment at 1300. Tolerated well. No cough. Reviewed and Approved: Shelly White CPT ATP-B-S:02:1001261385: Shelly White CPT 11 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. (Signed: 07/04/YYYY 01:06:45 PM EST) GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802  (607) 555-1234 12 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 PROGRESS NOTES Date Time Physician’s signature required for each order. (Please skip one line between dates.) 07/04/YYYY 1800 Intermittent positive pressure breathing treatment at 1800. Tolerated well. No cough. Reviewed and Approved: Rose Markam, CPT ATP-B-S:02:1001261385: Rose Markam, CPT (Signed: 07/04/YYYY 06:01:25 PM EST) 07/05/YYYY 0700 Intermittent positive pressure breathing treatment at 0700. Tolerated well. Dry cough released completion of 48 hours. Reviewed and Approved: Shelly White CPT ATP-B-S:02:1001261385: Shelly White CPT (Signed: 07/05/YYYY 07:07:45 AM EST) 07/05/YYYY 0800 Dry cough. Fever down. Improving with intermittent positive pressure breathing treatments. Serous otitis left ear. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/05/YYYY 08:02:30 AM EST) 07/06/YYYY 0800 Afebrile. Regaining strength. Home tomorrow if chest x-ray warrants. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/06/YYYY 08:06:45 AM EST) GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802  (607) 555-1234 13 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. 14 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 DOCTORS’ ORDERS Date Time Physician’s signature required for each order. (Please skip one line between dates.) 06-30-YYYY 1530 Complete blood count Urinalysis Chest X-ray done as outpatient. Get report. Electrocardiogram SCG II Electrolytes Sputum for culture and sensitivity Regular diet Aspirin, 650 milligrams every four hours for elevated temperature Bed rest with bathroom privileges Intermittent positive pressure breathing with saline four times a day for 48 hours Ampicillin 500 milligrams four times a day for 7 days History and physical exam dictated. Lanoxin, 0.125 milligram daily Lasix, 20 milligrams daily Klotrix one tablet three times a day Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 06/30/YYYY 03:33:12 PM EST) 07/01/YYYY 1115 Tylenol one or two tablets every four to six hours as needed for fever. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/01/YYYY 11:18:44 AM EST) 07/01/YYYY 1515 Dalmane 15 milligrams every bedtime as needed for sleep. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/01/YYYY 03:20:00 PM EST) 07/03/YYYY 0930 Discontinue Ampicillin. Erythromycin 500 milligrams every six hours for 5 days. Intermittent positive pressure breathing with saline four times a day for 48 hours Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/03/YYYY 09:32:12 AM EST) GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 15 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 DOCTORS’ ORDERS Date Time Physician’s signature required for each order. (Please skip one line between dates.) 07/04/YYYY 0800 Chest X-ray and Complete blood count scheduled for 07/05. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/04/YYYY 08:05:23 AM EST) 07/05/YYYY 1330 Dimetapp extentabs one tablet now then twice daily. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/05/YYYY 03:40:44 PM EST) 07/06/YYYY 1515 Afrin nasal spray – 2 squeezes in each nostril every 12 hours. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/06/YYYY 03:20:00 PM EST) 07/07/YYYY 0900 Discharge. Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 07/07/YYYY 09:02:12 AM EST) GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 16 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 RADIOLOGY REPORT Date of X-ray: 07/05/YYYY REASON: Pneumonia TECHNICAL DATA: Posteroanterior and lateral. CHEST: Posteroanterior and lateral views reveal partial clearing of the lingular pneumonia since 06/30/YYYY. There is now an area of consolidation In the lateral portion of the middle lobe. The lungs otherwise appear clear. CONCLUSION: Bilateral bacterial pneumonia. DD: 07/05/YYYY DT: 07/06/YYYY Reviewed and Approved: Randall Cunningham MD ATP-B-S:02:1001261385: Randall Cunningham MD (Signed:07/05/YYYY 02:24:44 PM EST) GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 17 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 RADIOLOGY REPORT Date of X-ray: 06/30/YYYY REASON: Rule out pneumonia. TECHNICAL DATA: Please call. 06/30/YYYY CHEST: Posteroanterior and lateral views reveal a small area of infiltrate in the lingual. This would be compatible with an acute pneumonia and a follow-up study is suggested. The heart is of normal size and the lungs otherwise appear clear. There is an old fracture in the lower thoracic spine and several old healing left rib fractures. DD: 06/30/YYYY DT: 07/01/YYYY Reviewed and Approved: Randall Cunningham MD ATP-B-S:02:1001261385: Randall Cunningham MD (Signed:06/30/YYYY 02:32:08 PM EST) GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 18 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 LABORATORY DATA SPECIMEN COLLECTED: IN: 06/30YYYY 1614 SPECIMEN RECEIVED OUT: 06/30/YYYY 1749 BLOOD CHEMISTRY 1 TEST REFERENCE RESULT ACID PHOSPHATASE 0.0-0.8 U/I ALKALINE PHOSPHATASE 50-136 U/I AMYLASE 23-85 U/I LIPASE 4-24 U/I GLUCOSE FASTING 70-110 mg/dl GLUCOSE Time collected BUN 7-22 mg/dl SODIUM 136-147 mEq/1 137 POTASSIUM 3.7-5.1 mEq/l **3.4** CARBON DIOXIDE 24-32 mEq/l 27 CHLORIDE 98-108 mEq/l 97 CHOLESTEROL 120-280 mg/dl SERUM GLUTAMATE PYRUVATE TRANSAMINASE 3-36 U/I SERUM GLUTAMIC OXALOCETIC TRANSAMINASE M-27-47 U/I F-22-37 U/I CREATININE KINASE M-35-232 U/I F-21-215 U/I LACTATE DEHYDROGENASE 100-190 U/I CREATININE M-0.8-1.3 mg/dl F-0.6-1.0 mg/dl CALCIUM 8.7-10.2 mg/dl PHOSPHORUS 2.5-4.9 mg/dl BILIRUBIN-DIRECT 0.0-0.4 mg/dl BILIRUBIN-TOTAL Less than 1.5 mg/dl TOTAL PROTEIN 6.4-8.2 g/dl ALBUMIN 3.4-5.0 g/dl URIC ACID M-3.8-7.1 mg/dl F-2.6-5.6 mg/dl TRIGLYCERIDE 30-200 mg/dl U/I = International Units g/dl = grams per deciliter mEq = millequivalent per deciliter mg/dl = milligrams per deciliter GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 19 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. 20 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 LABORATORY DATA SPECIMEN COLLECTED: IN: 06/30YYYY 2322 SPECIMEN RECEIVED OUT: 07/01/YYYY 1032 BLOOD CHEMISTRY 1 TEST REFERENCE RESULT ACID PHOSPHATASE 0.0-0.8 U/I ALKALINE PHOSPHATASE 50-136 U/I **10.4** AMYLASE 23-85 U/I LIPASE 4-24 U/I GLUCOSE FASTING 70-110 mg/dl 81 GLUCOSE Time collected BUN 7-22 mg/dl SODIUM 136-147 mEq/1 POTASSIUM 3.7-5.1 mEq/l CARBON DIOXIDE 24-32 mEq/l CHLORIDE 98-108 mEq/l CHOLESTEROL 120-280 mg/dl 138 SERUM GLUTAMATE PYRUVATE TRANSAMINASE 3-36 U/I SERUM GLUTAMIC OXALOCETIC TRANSAMINASE M-27-47 U/I F-22-37 U/I 42 CREATININE KINASE M-35-232 U/I F-21-215 U/I LACTATE DEHYDROGENASE 100-190 U/I **260** CREATININE M-0.8-1.3 mg/dl F-0.6-1.0 mg/dl **0.4** CALCIUM 8.7-10.2 mg/dl **8.3** PHOSPHORUS 2.5-4.9 mg/dl **2.2** BILIRUBIN-DIRECT 0.0-0.4 mg/dl BILIRUBIN-TOTAL Less than 1.5 mg/dl 1.2 TOTAL PROTEIN 6.4-8.2 g/dl **6.1** ALBUMIN 3.4-5.0 g/dl **3.2** URIC ACID M-3.8-7.1 mg/dl F-2.6-5.6 mg/dl **0.5** TRIGLYCERIDE 30-200 mg/dl U/I = International Units g/dl = grams per deciliter mEq = millequivalent per deciliter mg/dl = milligrams per deciliter GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 21 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 LABORATORY DATA SPECIMEN COLLECTED: 06/30/YYYY SPECIMEN RECEIVED: 06/30/YYYY TEST RESULT FLAG REFERENCE URINALYSIS DIPSTICK ONLY COLOR Yellow clear SP GRAVITY 1.005  1.030 ALBUMIN negative  125 mg/dl BILIRUBIN negative  0.8 mg/dl SUGAR negative  10 mg/dl BLOOD moderate 0.06 mg/dl hgb PH 7.5 5-8.0 ACETONE negative  30 mg/dl UROBILINOGEN  -1 mg/dl NITRITES NEG LEUKOCYTE  15 WBC/hpf W.B.C. rare  5/hpf R.B.C. 0-6/hpf  5/hpf BACT. 1+( 20/hpf) URINE PREGNANCY TEST ***End of Report*** GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802  (607) 555-1234 22 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 LABORATORY DATA TIME IN: 06/30/YYYY 1614 TIME OUT: 06/30/YYYY 1749 COMPLETE BLOOD COUNTS DIFFERENTIAL TEST RESULT FLAG REFERENCE WHITE BLOOD CELL 15.1 4.5-11.0 thou/ul RED BLOOD CELL 3.69 5.2-5.4 milliliter/ upper limit HEMOGLOBIN 11.8 11.7-16.1 grams per deciliter HEMATOCRIT 34.8 35.0-47.0 % MEAN CORPUSCULAR VOLUME 94.3 85-99 factor level MEAN CORPUSCULAR HEMOGLOBIN 32.1 MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION 34.0 33-37 RED CELL DISTRIBUTION WIDTH 11.4-14.5 PLATELETS 143 130-400 thou/ul SEGMENTED CELLS % 62 LYMPHOCYTES % 18 20.5-51.1 MONOCYTES % 12 1.7-9.3 EOSINOPHILS % 3 BAND CELLS % 5 Thou/ul= thousand upper limit COMMENTS: Few target cells ***End of Report*** GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 23 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 LABORATORY DATA TIME IN: 07/04/YYYY 1052 TIME OUT: 07/05/YYYY 1029 COMPLETE BLOOD COUNTS DIFFERENTIAL TEST RESULT FLAG REFERENCE WHITE BLOOD CELL 4.9 4.5-11.0 thou/ul RED BLOOD CELL 4.06 5.2-5.4 milliliter/ upper limit HEMOGLOBIN 12.8 11.7-16.1 grams per deciliter HEMATOCRIT 37.7 35.0-47.0 % MEAN CORPUSCULAR VOLUME 93 85-99 factor level MEAN CORPUSCULAR HEMOGLOBIN 31.7 MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION 34.1 33-37 RED CELL DISTRIBUTION WIDTH 11.4-14.5 PLATELETS 242 130-400 thou/ul SEGMENTED CELLS % 44 LYMPHOCYTES % 27 20.5-51.1 MONOCYTES % 6 1.7-9.3 EOSINOPHILS % 14 BAND CELLS % 8 Thou/ul= thousand upper limit COMMENTS: Occasional target cells ***End of Report*** GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 24 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 LABORATORY DATA SPECIMEN COLLECTED: 07-02-YYYY SPECIMEN RECEIVED: 07-06-YYYY TEST RESULT BACTERIOLOGY SOURCE: Sputum SMEAR ONLY: 1+ gram positive cocci; rare white blood cells CULTURE 1st PRELIMINARY 1+ gram negative rod 2nd PRELIMINARY OTHER ROUTINE CULTURES FINAL REPORT 1+ Enterobacter cloacae SENSITIVITIES ***End of Report*** GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802  (607) 555-1234 25 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 EKG REPORT Date of EKG: 06/30/YYYY Time of EKG 1005 Rate 112 Sinus tachycardia. Myocardial changes of inferior ischemia progressive from 01/09/YYYY. Occasional premature ventricular contraction. PR 12 QRSD .08 QT .32 QTC — Axis — P QRS T Reviewed and Approved: Bella Kaplan, MD ATP-B-S:02:1001261385: Bella Kaplan, MD (Signed: 07/01/YYYY 5:24:44 PM EST) GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 26 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 MEDICATION ADMINISTRATION RECORD SPECIAL INSTRUCTIONS: Allergic to Aspirin MEDICATION (dose and route) DATE: 06/30 DATE: 07/01 DATE: 07/02 DATE: 07/03 TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALS Ampicillin 500 milligrams 4 times a day for 7 days 0800 —- 0800 VS 0800 VS 0800 VS 1200 —- 1200 VS 1200 VS 1200 —- 1600 OR 1600 OR 1600 OR 1600 —- 2000 OR 2000 OR 2000 OR 2000 —- Lanoxin 0.125 milligrams daily 0800 — 0800 VS 0800 VS 0800 VS Lasix 20 milligram daily 0800 VS 0800 VS 0800 VS 0800 VS Klotrix 1 tablet three times a day 0800 —- 0800 VS 0800 VS 0800 VS 1300 —- 1300 VS 1300 VS 1300 VS 1800 OR 1800 OR 1800 OR 1800 OR Erythromycin 500 milligrams every 6 hours for 5 days 0600 —- —- —- 0600 —- 1200 —- —- —- 1200 VS 1800 —- —- —- 1800 OR 2400 —- —- —- 2400 JD Single Orders PRN Medications Aspirin 650 milligrams by mouth every 4 hours as needed for elevated temperature 1530 OR 1215 VS 1930 OR 1805 OR Tylenol 1 or 2 tablets by mouth every 4-6 hours as needed for fever —- —- 1530 OR 0800 VS 0820 VS —- —- 1950 OR 1600 OR 2345 OR Dalmane 15 milligrams by mouth every night at bedtime as needed for sleep —- —- 2220 OR 2200 OR 2140 OR INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE VT Vera South, RN GPW G. P. Well, RN OR Ora Richards, RN PS P. Small, RN JD Jane Dobbs, RN HF H. Figgs, RN GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 27 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 MEDICATION ADMINISTRATION RECORD SPECIAL INSTRUCTIONS: Allergic to Aspirin MEDICATION (dose and route) DATE: 07/04 DATE: 07/05 DATE: 07/06 DATE: 07/07 TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALS Erythromycin 500 milligrams every 6 hours for 5 days 0600 JD 0600 JD 0600 JD 0600 JD 1200 VS 1200 VS 1200 VS 1200 —- 1800 OR 1800 OR 1800 OR 1800 —- 2400 JD 2400 JD 2400 JD 2400 —- Lanoxin 0.125 milligrams daily 0800 VS 0800 VS 0800 VS 0800 VS Lasix 20 milligram daily 0800 VS 0800 VS 0800 VS 0800 VS Klotrix 1 tablet three times a day 0800 VS 0800 VS 0800 VS 0800 VS 1300 VS 1300 VS 1300 VS 1300 —- 1800 OR 1800 OR 1800 OR 1800 —- Dimetapp Extentabs 0800 VS 0800 VS 0800 VS 2000 OR 2000 OR Afrin nasal spray 2 squeezes each nostril every 12 hours 0800 —- 0800 VS 2000 OR 2000 —- PRN Medications: Tylenol 1 or 2 tablets every 4-6 hours as needed for pain 0830 JD Dalmane 15 milligrams every bedtime as needed for sleep 2200 OR 2230 OR INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE VT Vera South, RN GPW G. P. Well, RN OR Ora Richards, RN PS P. Small, RN JD Jane Dobbs, RN HF H. Figgs, RN GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 28 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 NURSES’ NOTES DATE TIME TREATMENTS & MEDICATIONS TIME NURSES’ NOTES 06/30/YYYY 1530 Wednesday Aspirin 650 milligrams for elevated temperature. 1515 Resting in bed. Reminded patient to save sputum for specimen and urine for specimen. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 06/30/YYYY 03:31:03 PM EST) 1700 Regular diet 1700 Ate fair amount at dinner. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 06/30/YYYY 05:07:41 PM EST) 1930 101-104-20 126/70 Aspirin 650 milligrams for elevated temperature. Urine specimen sent to lab. 1900 Resting in bed. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 06/30/YYYY 07:31:41 PM EST) 2000 Evening care given. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 06/30/YYYY 08:06:03 PM EST) 2230 Resting quietly in bed. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 06/30/YYYY 10:33:44 PM EST) 07/01/YYYY 2400 Thursday 100.2-100-20 Aspirin 650 milligrams for elevated temperature. 2400 Awake. Mild cough. Coughs occasionally. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 07/01/YYYY 12:03:16 AM EST) 0300 Sleeping. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 07/01/YYYY 03:08:22 AM EST) 0600 0615 101.2-96-20 Aspirin 650 milligrams for elevated temperature. 0600 Awake for temperature, pulse, and respirations. Slept well most of the night. Medicine for elevated temperature. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 07/01/YYYY 06:03:16 AM EST) 07/01/YYYY 0700 Appetite good for breakfast. Regular diet. Non-productive cough noted. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 07/01/YYYY 07:05:33 AM EST) 1200 Lunch taken and tolerated well. Resting quietly in bed. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/01/YYYY 12:16:00 PM EST) LOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 29 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 NURSES’ NOTES DATE TIME TREATMENTS & MEDICATIONS TIME NURSES’ NOTES 07/01/YYYY 1511 1530 Temperature 102.2 Tylenol 2 tablets for elevated temperature. 1515 Resting in bed. Skin warm and moist. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/01/YYYY 03:36:00 PM EST) 1700 Regular diet. 1700 Ate moderate amount at dinner. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/01/YYYY 05:05:12 PM EST) 1900 100.3-100-20 120/60 1900 Resting in bed. Taking fluids well. Coughing no sputum for specimen. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/01/YYYY 07:05:07 PM EST) 1950 Tylenol 2 tablets for elevated temperature. 2000 Evening care given. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/01/YYYY 08:02:41 PM EST) 2230 Resting quietly in bed. Non-productive cough noted. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/01/YYYY 10:32:01 PM EST) 07/02/YYYY 2400 Friday 99-100-24 2400 Sleeping on first rounds. Awakened for Temperature, pulse, and respirations. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 07/02/YYYY 12:04:00 AM EST) 0600 Slept well through most of the night. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 07/02/YYYY 06:08:44 AM EST) Tylenol 2 tablets given by mouth. 0730 Awake. Vitals stable. Elevated temperature 101.8. Encouraged to drink fluids. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/02/YYYY 07:32:00 AM EST) 0800 Breakfast taken fair. Bathroom without assistance. Self morning care. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/02/YYYY 08:04:22 AM EST) 0900 Dr. Black is in. 0900 Patient working on sputum. Face appears slightly flushed and eyes very bright. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/02/YYYY 09:02:13 AM EST) GLOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 30 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 NURSES’ NOTES DATE TIME TREATMENTS & MEDICATIONS TIME NURSES’ NOTES 07/02/YYYY 1200 Lunch taken fair. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/02/YYYY 12:02:17 PM EST) 1400 Resting. Still working on sputum specimen. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/02/YYYY 02:03:00 PM EST) 07/02/YYYY Temperature 101 1530 Resting quietly in bed. Temperature elevated. States not coughing up as much as previously. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/02/YYYY 03:32:50 PM EST) 1730 Diet taken poorly. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/02/YYYY 05:31:03 PM EST) 99.9-64-20 144/70 1930 Vitals taken. Complained of ears feeling very “full.” Working at sputum collection. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/02/YYYY 07:37:41 PM EST) 2030 Bedtime care given. No productive cough noted. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/02/YYYY 08:32:28 PM EST) 2215 Out of bed to bathroom. Back to bed. Comfortable. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/02/YYYY 10:16:03 PM EST) 07/03/YYYY Saturday 2400 Awakened. Asked for Tylenol for headache. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 07/03/YYYY 12:04:00 AM EST) 0600 Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 07/03/YYYY 12:04:00 AM EST) 0730 To bathroom for self morning care and returned to room. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South , RN (Signed: 07/03/YYYY 07:37:11 AM EST) GLOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 31 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 NURSES’ NOTES DATE TIME TREATMENTS & MEDICATIONS TIME NURSES’ NOTES 07/03/YYYY 1200 Out of bed in chair for lunch. Ate well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/03/YYYY 12:06:00 PM EST) 1400 Resting quietly. No complaints offered. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/03/YYYY 02:02:20 PM EST) 1530 Resting in bed visiting with family. Offers no complaint of discomfort at present. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/03/YYYY 03:32:40 PM EST) 1700 Ate very poor regular diet. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/03/YYYY 05:02:40 PM EST) 1930 Temperature 101.2 1900 Sleeping soundly. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/03/YYYY 07:32:40 PM EST) 2020 Tylenol 2 tablets for elevated temperature. 2030 Bedtime care given. Temperature elevated a little. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/03/YYYY 08:31:34 PM EST) 2200 Appears to be sleeping. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/03/YYYY 10:03:00 PM EST 07/04/YYYY 2400 Sunday 97.7–76-24 2400 Sleeping on first rounds. Awakened for temperature, pulse, and respirations. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs RN (Signed: 07/04/YYYY 12:01:00 AM EST) 0300 Sleeping. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs RN (Signed: 07/04/YYYY 03:02:20 AM EST) 0600 Slept well most of the night. Still sounds congested. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs RN (Signed: 07/04/YYYY 06:05:46 AM EST) 32 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. GLOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 NURSES’ NOTES DATE TIME TREATMENTS & MEDICATIONS TIME NURSES’ NOTES 07/04/YYYY 0800 Dr. Black is in. 0800 Breakfast taken well. Self morning care taken in bathroom. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs RN (Signed: 07/04/YYYY 08:05:46 AM EST) 1000 Out of bed sitting in chair, watching television. No cough noted. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/04/YYYY 10:07:13 AM EST) 1200 Lunch taken well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/04/YYYY 12:04:00 PM EST 1400 Resting quietly. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/04/YYYY 02:03:45 PM EST 07/04/YYYY Temperature 99.6 1530 Awake resting quietly in bed, complains of being hungry and requested coffee and cookies—given to her. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/04/YYYY 03:34:20 PM EST 1700 Ate very good dinner. Resting quietly. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/04/YYYY 05:33:12 PM EST 2030 Temperature 99.8 Tylenol 2 tablets for elevated temperature. 2000 Complains of being cold. Temperature elevated. Given more blankets. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/04/YYYY 08:36:50 PM EST) 2200 Appears to be sleeping soundly. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/04/YYYY 10:03:34 PM EST) 07/05/YYYY 2400 Monday 96.9-88-16 2400 Sleeping on first rounds. Awakened for temperature, pulse, and respirations. Skin warm and moist. Pajamas changed and made comfortable. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 07/05/YYYY 12:05:00 AM EST 0300 Sleeping soundly. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 07/05/YYYY 03:03:10 AM EST) 33 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. GLOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 NURSES’ NOTES DATE TIME TREATMENTS & MEDICATIONS TIME NURSES’ NOTES 07/05/YYYY Monday 0600 Slept well most of the night. Still sounds congested. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 07/05/YYYY 06:02:49 AM EST) 0730 Morning vitals taken. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/05/YYYY 07:37:13 AM EST) 0800 Breakfast taken fairly well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/05/YYYY 08:02:23 AM EST) 0830 Self morning care in the bathroom. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/05/YYYY 08:32:00 AM EST) 1000- 1100 Patient out in chair sitting for most of the morning. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/05/YYYY 11:02:00 AM EST) 1200 Dr. Black is in. Patient takes lunch fairly well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/05/YYYY 12:04:20 PM EST) 1300- 1400 Patient resting quietly in bed and offered no complaints. Had a fairly good day. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/05/YYYY 02:01:46 PM EST) 1530 Resting quietly in bed. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/05/YYYY 03:32:17 PM EST) 1700 Ate well at dinner. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/05/YYYY 05:03:10 PM EST 1900 Up and about in room. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/05/YYYY 07:02:00 PM EST) 34 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. GLOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 NURSES’ NOTES DATE TIME TREATMENTS & MEDICATIONS TIME NURSES’ NOTES 07/05/YYYY Monday 2000 Evening care given. Voiding quantity sufficient in bathroom. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/05/YYYY 08:02:00 PM EST) 2230 Resting in bed. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/05/YYYY 10:32:50 PM EST) 07/06/YYYY Tuesday 2400 Asleep on rounds. Respirations sound a little full. Side rails up. No complaints. Reviewed and Approved: J. Dodds, RN ATP-B-S:02:1001261385: J. Dodds, RN (Signed: 07/06/YYYY 12:02:49 AM EST) 0300 Continues to sleep. Reviewed and Approved: J. Dodds, RN ATP-B-S:02:1001261385: J. Dodds, RN (Signed: 07/06/YYYY 03:04:09 AM EST) 0600 Remains sleeping this morning. No cough noted. Reviewed and Approved: J. Dodds, RN ATP-B-S:02:1001261385: J. Dodds, RN (Signed: 07/06/YYYY 06:02:19 AM EST) 07/06/YYYY 0800 98.9-92-20 132/78 Regular diet 0800 Self morning care in bathroom. Ate well for breakfast. No complaints. Occasional harsh cough noted. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/06/YYYY 08:12:55 AM EST) 1200 Regular diet Temperature 97.2 1200 Ate well for lunch. Ambulated as desired. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/06/YYYY 12:05:45 PM EST) 1430 Dr. Black in. 1430 Comfortable day. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/06/YYYY 02:32:55 PM EST) 07/06/YYYY 1530 Resting in bed. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/06/YYYY 03:32:17 PM EST) 1700 Regular diet. 1700 Ate well at dinner. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/06/YYYY 05:02:17 PM EST) 35 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. GLOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 NURSES’ NOTES DATE TIME TREATMENTS & MEDICATIONS TIME NURSES’ NOTES 07/06/YYYY Tuesday 1900 Up and about in room. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/06/YYYY 07:02:17 PM EST) 1930 99.3-80-20 100/64 2000 Evening care given. Took bedtime snack Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/06/YYYY 08:01:34 PM EST) 2230 Resting quietly in bed. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 07/06/YYYY 10:34:06 PM EST) 07/07/YYYY 11-7 Wednesday 2400 Asleep on rounds. No complaints. Respirations sounding more clear. Side rails up. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385:J. Dobbs, RN (Signed: 07/07/YYYY 12:03:07 AM EST) 0300 Continues to sleep. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385:J. Dobbs, RN (Signed: 07/07/YYYY 03:01:17 AM EST) 0600 Slept fairly well throughout the night. Respirations clear. No complaints. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385:J. Dobbs, RN (Signed: 07/07/YYYY 06:05:38 AM EST) 07/07/YYYY 0730 Awake. Vitals stable. Anxious for discharge. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385:J. Dobbs, RN (Signed: 07/07/YYYY 07:03:27 AM EST) 0800 Took breakfast well – appetite good. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/07/YYYY 08:04:53 AM EST) Dr. Black in. Discharged to home. 0900 Morning care done. No complaints. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/07/YYYY 09:02:12 AM EST) 1000 Discharged to home. Instructions given to patient. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/07/YYYY 10:02:23 AM EST) 36 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. GLOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 NURSING DISCHARGE STATUS SUMMARY 1. AFEBRILE: X Yes No 140/80 98 – 80 – 20 2. WOUND: Clean/Dry Reddened Infected NA X 3. PAIN FREE: Yes X No If “No,” describe: Requires Tylenol as needed. 4. POST-HOSPITAL INSTRUCTION SHEET GIVEN TO PATIENT/FAMILY: Yes X No If NO, complete lines 5-8 below. 5. DIET: X Regular Other (Describe): 6. ACTIVITY: X Normal Light Limited Bed rest 7. MEDICATIONS: None 8. INSTRUCTIONS GIVEN TO PATIENT/FAMILY: As ordered by Dr. Black 9. PATIENT/FAMILY verbalize understanding of instructions: X Yes No 10. DISCHARGED at 1000 Via: Wheelchair X Stretcher Ambulance Co. Ambulatory Accompanied by: Vera South, RN to Front lobby COMMENTS: To front lobby. Ambulated with assistant to home with family. Cast on left arm. DATE: 07/07/YYYY SIGNATURE: Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 07/07/YYYY 10:02:15 AM EST GLOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234 37 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY IPCase006 Dr. BLACK Admission: 06/30/YYYY DOB: 06/23/YYYY ROOM: 0371 PATIENT PROPERTY RECORD I understand that while the facility will be responsible for items deposited in the safe, I must be responsible for all items retained by me at the bedside. (Dentures kept the bedside will be labeled, but the facility cannot assure responsibility for them.) I also recognize that the hospital cannot be held responsible for items brought in to me after this form has been completed and signed. Reviewed and Approved: Sally Pire ATP-B-S:02:1001261385: Sally Pire (Signed: 06/30/YYYY 01:35:05 PM EST) 06/30/YYYY Signature of Patient Date Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 06/30/YYYY 01:37:23 PM EST 06/30/YYYY Signature of Witness Date I have no money or valuables that I wish to deposit for safekeeping. I do not hold the facility responsible for any other money or valuables that I am retaining or will have brought in to me. I have been advised that it is recommended that I retain no more than $5.00 at the bedside. Reviewed and Approved: Sally Pire ATP-B-S:02:1001261385: Sally Pire (Signed: 06/30/YYYY EST) 01:38:00 PM 06/30/YYYY Signature of Patient Date Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 06/30/YYYY EST) 01:39:18 PM 06/30/YYYY Signature of Witness Date I have deposited valuables in the facility safe. The envelope number is . Signature of Patient Date Signature of Person Accepting Property Date I understand that medications I have brought to the facility will be handled as recommended by my physician. This may include storage, disposal, or administration. Signature of Patient Date Signature of Witness Date GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234