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Sundance HealthCare Systems

Painted Valley, USA


Newman, Edward C.
Dr. William J. Wainwright
NAME Newman, Edward C. X-RAY NO. 47932 Coronary care unit
DOCTOR Dr. W. J. Wainwright DATE 8/14/xx # 012502

REGION EXAMINED
CHEST X-RAY

Indications: SOB

CHEST: There is mild to moderate pulmonary vascular congestion. There is mild bilateral interstitial
edema. The findings are less prominent than on 1-1-xx. No focal consolidation is seen in
the lungs.

WCR/smb

William C. Roentgen M.D.


RADIOLOGIST'S SIGNATURE

© 2003. American Health Information Management Association. All rights reserved.


Sundance Medical Center
Painted Valley, USA Patient Name: Newman, Edward C.
Physician: Dr. William J. Wainwright
Room No. Coronary care unit
# 012502

Instructions: Please follow the instructions given below. This is an important part of your continued
recovery. If, after reading the instructions, you have any questions please ask your physician/nurse for
clarification.

Diet: 1500 calorie ADA, no added salt diet.

Medications: Diazepam 20 mg p.o. q.h.s., albuterol and Atrovent nebulizers q.d. and p.r.n., Lasix 160

mg p.o. b.i.d.; Theo-Dur 200 mg q.a.m., 300 mg q.h.s.; Imdur 30 mg (1/2 tab) q.h.s., Pilocarpine 4% 1

drop O.D. q.i.d., nitroglycerin 0.4 mg sublingual p.r.n. chest pain, oxygen 2 to 4 liters per minute per nasal

cannula. Diabetes meds will be: Humulin N 64 U a.m., Humulin N 36 U p.m. and Humalog sliding scale:

Accu-Chek less than 100 = 0, Accu-Chek 221 - 300 = 12,


Accu-Chek 101 - 130 = 3, Accu-Chek 301 - 400 = 15,
Accu-Chek 131 - 170 = 5, Accu-Chek less than 400 = 18.
Accu-Chek 117 - 220 = 8,

Activity: As tolerated.

Follow-Up: Mr. Newman has an appointment to see me in the office in approximately

two weeks for recheck. He should call or come in sooner if he has any questions or

problems prior to that appointment.

I have read the above instructions and received a copy of them. They were explained to me and all my
questions were answered satisfactorily.

a.m.
Edward C. Newman 8/14/xx 6:45 p.m. William J. Wainwright
Patient's Signature Date Time Attending Physician

DISCHARGE INSTRUCTIONS SHEET


© 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Newman, Edward C.
Painted Valley, USA Dr. William J. Wainwright
Coronary care unit
Date/
Time Orders Progress Notes # 012502
8/14 Admit to CCU per Dr. Wainwright. 78 y.o. male with severe COPD, IDDM,
DX: CHF, COPD. ASHD admitted with increased dyspnea.
Condition stable See H&P. Wainwright
Vitals q.4h. while awake, daily weight. William J. Wainwright
William J. Wainwright
0010 ALL: PCN -> Hives
Diet - No added salt
Activity Up to BR
IV saline lock
Meds: Lasix 80 mg IV now
Humulin N 64 U SQ q.a.m.
Humulin N 36 U SQ q.p.m.
Humalog 12 U AC t.i.d.
Hold if BS <120
Theo-Dur 200 mg p.o. b.i.d.
Lasix 160 mg p.o. b.i.d.
EC ASA 1 p.o. daily
Imdur 60 p.o. q.h.s.
Diazepam 10 mg p.o. q.h.s.
Clorazepate 15 mg q.h.s.
nitroglycerin 0.4 mg SL p.r.n. chest pain
Pilocarpine 4% ophthalmic drops 1 drop O.D. q.i.d.

0011 O2 - keep sats above 88%


William J. Wainwright
0012 Albuterol nebs q.i.d. p.r.n.
O2 William J. Wainwright

Form # _ _ _ _ Physician Orders and Progress Notes


© 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Newman, Edward C.
Painted Valley, USA Dr. William J. Wainwright
Coronary care unit
Date/
Time Orders Progress Notes # 012502
8/15 LAB: CBC, CMP, theo level, UA, TSH Progress Note: 8/15
Lisinopril 20 mg p.o. q.a.m. Social Services report from yesterday
EKG üdone ER indicated pt currently uses no services.
CXR state, check if done ER Will follow.
P-8 in a.m. 8/15 W. Scarlett, MSW
Oximetry daily while on O2
Foley to gravity William J. Wainwright

8/15 May request Valium 10 mg q.h.s. p 3 hr p.m. x1


Accu-Chek q.i.d.
EKG in a.m.
Atrovent inhaler two puffs q.i.d.
William J. Wainwright

8/15 Change Atrovent inhaler to SVN’s q.i.d.


v.o. Dr. Wainwright/rla William J. Wainwright
8/15 Breathing easier
8/15 @ 0945 Humalog q.i.d. S.S. 110/60, P 80
< 100 = 0 Lungs clear, distant BS
101 - 130 = 3 Heart - regular
131 - 170 = 5 Abd soft
171 - 220 = 8 Ext no edema
221 - 300 = 12 Weight down 6 #
301 - 400 = 15
- CHF
D/C H.s. Chlorazepate - IDDM
Inc Diazepam to 20 mg p.o. q.h.s. Increase activity
Ativan 2 mg p.o. t.i.d. p.r.n. anxiety Monitor O2 sats
Up walking William J. Wainwright Dr. Wagner
William J. Wainwright
8/15 @ 1410 D/C Humalog 12 u a.c. t.i.d.
T.O. Sally Mertz, RPO Sall;y J. Mertz, RPO

Form # _ _ _ _ Physician Orders and Progress Notes


© 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Newman, Edward C.
Painted Valley, USA Dr. William J. Wainwright
Coronary care unit
Date/
Time Orders Progress Notes # 012502

8/16 @ 0650
MOM 30 cc p.o. QP p.r.n.
S.O. Dr. Wainwright, A. May, RN
William J. Wainwright

8/16 D/C Foley, D/C CCU, D/C IV


William J. Wainwright

8/16 Discharge
Meds: Humulin N 64 U a.m.
Humulin N 36 U p.m.
Humalog sliding scale
Accu-Chek
William J. Wainwright

Units
< 100 = 0
101 - 130 = 3
131 - 170 = 5
171 - 220 = 8
221 - 300 = 12
301 - 400 = 15
> 400 = 18
Diazepam 20 mg p.o. q.h.s.
albuterol & Atrovent SVN’s q.i.d. & p.r.n.
Lasix 160 mg p.o. b.i.d.
Theo-Dur 200 mg q.a.m., 300 mg q.h.s.
Imdur 30 mg (1/2 tab) q.h.s.
Pilocarpine 4% 1 drop O.D. q.i.d.
nitroglycerin 0.4 mg SL p.r.n. chest pain
O2 2 to 4 L/m N.C.
Appt. my office - 2 wks
William J. Wainwright

Form # _ _ _ _ Physician Orders and Progress Notes


© 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Newman, Edward C.
Painted Valley, USA Dr. William J. Wainwright
Date/ Coronary care unit
Time Nursing Progress Notes
# 012502
8/14/xx
0805 Admission Admitted to CCU-3 per w/c from ER. Settles into bed with no c/o @ present.
See admission sheet. HRM, RN Brenda Kellye, RN

0845 Foley catheter inserted. Tolerated well. Brenda Kellye, RN

0900 Lisinopril 20 mg p.o. now given per order, Lasix 80 mg IV now given per order.
Brenda Kellye, RN

1000 Visiting with wife in room. No c/o at present. Brenda Kellye, RN

1300 Dozing in bed quietly. Brenda Kellye, RN

1500 Visiting in room with family. No c/o. Brenda Kellye, RN

1900 Summary Appetite good. Denies pain. Resting quietly. Wife @ bedside. Rhythm unchanged.
Leslie Scorch, RN

2200 Summary Uneventful evening, denies pain. Does become SOB with activity, respirations
easy @ rest. No c/o. Leslie Scorch, RN

8/15/xx
0115 SOB Resting awake in bed, had “Charley Horse” in leg. Better now, but dyspneic, resp
30/m et breathing rapidly, feels winded. LS dim throughout with left base crackles. Patient
quite anxious. Robert K. Russo, RN

0115 SVN with albuterol 0.5 cc given. Robert K. Russo, RN

0130 Breathing easier, increased air exchange throughout. Lungs fields with bibasilar crackles now.
Feeling better, remains anxious. Robert K. Russo, RN

0150 Valium 10 mg p.o. repeated Robert K. Russo, RN

0600 Awakened for assessment, had been sleeping. Becomes dyspneic on exertion with mild
dyspnea with rest. LS remains dim throughout. Crackles lower 1/2 left and 1/4 left.
Admits to feeling SOB, wants treatment. Robert K. Russo, RN

Nursing Progress Notes


© 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Newman, Edward C.
Painted Valley, USA Dr. William J. Wainwright
Coronary care unit
Date/
Time Nursing Progress Notes # 012502
8/15/xx
0615 SVN given with albuterol and atrovent Robert K. Russo, RN

0625 Feeling better after treatment. Increased air exchange to lung fields though crackles remain,
still has c/o feeling slightly SOB. Robert K. Russo, RN

0630 Lasix 160 mg p.o. given Robert K. Russo, RN

0800 Resting well. Upon awakening slightly SOB. Sats 91-92% on 2 liters. Dim LS with faint
bibasilar crackles. BS pos, Abd. neg. Ext. no edema. VS stable. Patient alert & oriented.
Brenda Kellye, RN

0830 Wife here. Patient eating. No c/o. Brenda Kellye, RN

1000 Resting now. Resp. more at ease. Brenda Kellye, RN

1030 Explained new S.S. insulin to patient and wife. No c/o, questions.
Brenda Kellye, RN

1230 Stable. Resting. Resp. easy. Brenda Kellye, RN

1300 Tried pt on 1L O2/NC, sats decrease to 87%. Increased to 2L/NC, sats 95%. Amb with
2LO2, 2 assist & Sat monitor on, 100 Fahrenheit. Sats to 92%. Back to room & up in chair.
Did get slightly dyspneic with amb. More rested in chair. Sats back up 95% when sitting.
Anne Odinson, RN

1400 Back to bed with 2LO2. Sats 98%. No c/o. Restful. Lights out for a bit. Call light placed.
Anne Odinson, RN

1450 Resting with easy, snoring like resp. Wife in room. Anne Odinson, RN

1600 Pt awake & talkative. Denies any discomfort. Resp easy at rest. Still has coarse rales in bases
bilaterally. Color pink. Sats in mid 90’s on 2L. No pedal edema. C/o some weakness.
Leslie Scorch, RN

Nursing Progress Notes


© 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Newman, Edward C.
Painted Valley, USA Dr. William J. Wainwright
Coronary care unit
Date/
Time Nursing Progress Notes # 012502
8/15/xx
1830 Appetite good. Assisted to ambulate 100 ft in hall with 2 assist & cont O2. Only slight
staggered steps at times. Otherwise gait steady. To BR but unable to have BMO.
Passed flatus. Had prune juice with supper. Leslie Scorch, RN

1930 VSS, resting quietly, denies physical c/o. Lungs diminished BS, O2 decreased 1/4 lit with
some crackles, dec 1/4 lit SO2 96% @ 2L/NC. Re AP, inc pulses x 2, no c/o. Soft abd,
Pos BS x 4, Foley patent with clear yellow urine. Leslie Scorch, RN

2030 Bath done, cares done. Linen changed. Leslie Scorch, RN


2050 Accu ü Accuü 105, pt given Humalog 3 units. Pt h.s. snack.
Leslie Scorch, RN

2105 SVN SVN with V.S. Albuterol & Atrovent given, tolerated well.
Leslie Scorch, RN

8/16/xx
0200 Sleeping in bed, breathing easily. Robert K. Russo, RN

0115 SVN with albuterol 0.5 cc given. Robert K. Russo, RN

0130 Breathing easy, good air exchange. Lungs fields with only minor crackles. No c/o at
this time. Robert K. Russo, RN

0640 Feels better after treatment. Improving air flow in all lung fields. Foley catheter removed.
IV discontinued. Robert K. Russo, RN

0700 Up to BR, voids well. Robert K. Russo, RN

0800 Dr. Wainwright visits, discharge order written and discharge instructions given. Patient resting
well. Blood sugar 130, vital signs stable. Ext. no edema. VS stable. Patient alert & oriented.
Brenda Kellye, RN

0830 Wife here. Patient eating. No c/o. Breakfast, eats well, somewhat short of breath while
eating, otherwise no dyspnea, no c/o. Brenda Kellye, RN

Nursing Progress Notes


© 2003. American Health Information Management Association. All rights reserved.
Sundance Medical Center Newman, Edward C.
Painted Valley, USA Dr. William J. Wainwright
Date/ Coronary care unit
Time Nursing Progress Notes # 012502
8/16/xx
1045 Discharge instructions discussed with patient and wife. They voice understanding. Will
follow up with Dr. Wainwright at his office in two weeks. Brenda Kellye, RN

1115 Discharged per wheelchair, escorted to car. Brenda Kellye, RN

Nursing Progress Notes


© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
Patient Family Name First Name Age Room No. Hosp. No.
Newman, Edward C. 78 CCU #2 # 012502
Attending Physician Date Lab. No.
Dr. William J. Wainwright 8/14/xx 7734-2002

Component Normal First Second Third Fourth


Date 08/14/xx

Color Yellow Yellow


Character Clear Clear
Spec Gravity 1.020 or less 1.015
Leukocytes Negative Negative
Nitrates Negative Negative
PH 5-6 5.2
Protein Urine Negative Negative
Glucose Urine Negative Negative
Ketones Urine Negative Negative
Urobilinogen 0 - 1 mg/dl Negative
Bilirubin Urine Negative Negative
Occ Blood Urine Negative Negative
WBC/HPF 0-5 3-5
RBC/HPF 0-5
Epitheial Few
Casts/LPF 15-20 Hylalin
Crystals
Amorphorus
Mucous
Yeast Cells Negative
Bacteria Negative

Sent for Culture: Y / N Y / N Y / N Y / N

24 Hour Urine 0 - 30
for Microalbumin

Form L-9001 (5/01) pa URINALYSIS


© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems
Painted Valley, USA Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
Diagnosis: CHF, COPD # 012502
Allergies: Penicillin

Medication and Hosp Day Hosp Day Hosp Day Hosp Day
Date of Order Route 8/14 #1 8/15 # 8/16#3 #4
1. Lisinopril 40 mg p.o. q.a.m. 08 SMB SGA

2. Theo-Dur 200 mg p.o. b.i.d. 08 ams SMB KJN

3. 21 nmr kl

4. Lasix 160 mg p.o. b.i.d. 08 ams 1200 SMB KJN

5. 17 pvm rlw KJN

6. EC ASA 1 p.o. daily 08 ams SMB KJN

7. Imdur 60 p.o. q.h.s. 21 nh kl

8. Diazepam 10 mg p.o. q.h.s. 21 nh see D’s below

9. Pilocarpine 4% 1 gtt OD q.i.d. 08 / SMB KJN

10. 12 pvm SMB

11. 16 mds swb

12. 21 taf ko

13. Clorazepate 15 mg q.h.s. 21 wlk dcd 8/15

14. Diazepam 20 mg p.o. q.h.s. 21 / ko

15.

16.

17.

18.

19.

20.

MEDICATION PROFILE
© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
Patient Family Name First Name Age Room No. Hosp. No.
Newman, Edward C. 78 CCU #2 # 012502
Attending Physician Date Lab. No.
Dr. William J. Wainwright 8/14/xx 7734-2002

Component Normal First Second Third Fourth


Date 08/14/xx 08/15/xx

Chemistry 10
Sodium 135 - 145 143 143
Potassium 3.5 - 5.3 4.4 3.8
Chloride 100 - 110 100 100
CO2 23 - 29 35 H 36 H
Glucose 80 - 116 238 H 91
BUN 12 - 20 27 H 35 H
Creatinine 0.6 - 1.3 1.5 H 1.6 H
Total Bili 0.0 - 1.3 0.7
Albumin 3.5 - 5.0 3.9
Calcium 8.2 - 10.1 9.8 9.4

ALP 56 - 112 58
AST 0 - 27 21
ALT 14 - 26 18
Total Protein 6.0 - 8.0 6.6

Theo 10.0 - 20.0 8.2 L


TSH 0.4 - 6.2 1.9

Lipid Profile
Total Choles 100 - 200
HDL 40 - 80
LDL 66 - 130
Triglycerides 50 - 150

HG A1C 4.0 - 6.0

PSA 0.0 - 4.0

Form L-9003 (5/01) pa CHEMISTRY


© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Painted Valley, USA
Patient Family Name First Name Age Room No. Hosp. No.
Newman, Edward C. 78 CCU #2 # 012502
Attending Physician Date Lab. No.
Dr. William J. Wainwright 8/14/xx 7734-2002

Component Normal First Second Third Fourth


Date 08/14/xx

Hematology
WBC (x 103) M/F 4.3 - 11.0 10.4 H
RBC (x 103) M 4.6 - 6.2 4.25
F 4.2 - 5.4
Hgb (g/dl) M 12 - 18 13.6
F 12 - 16
HCt (%) M 40 - 54 40.6
F 36 - 47
MCV (x 103) M 80 - 94 95.7
F 82 - 100
MCH (x 103) M/F 26 - 33 32.0
MCHC (%) M/F 31 - 36 33.4
PLT (x 103) M/F 150 - 375

Differential
Band 0 - 6%
Seg 46 - 82% 76
Lymph 13 - 37% 15
Mono 4 - 12% 4
Eosin 0 - 5% 3
Baso 2 - 2% 3 H
NRBC
Atyp Lymph
Meta
Myelo
Pros
Blast

Form L-9003 (5/01) pa HEMATOLOGY


© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems
Painted Valley, USA Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
# 012502

CHIEF COMPLAINT: Shortness of breath.

HISTORY OF PRESENT ILLNESS: This patient is a 78-year-old resident of Podunk Center. He has a
long-standing history of severe COPD, insulin-dependent diabetes mellitus and ASHD and status post MI’s.

According to the patient he has been severely short of breath over the past several months. Apparently this has
increased over the past two days and yesterday it severely limited his ability to get up and walk around. During
the night last night, at approximately 5:00 a.m., he had a severe episode of shortness of breath. He received
two nebulizer treatments and his wife turned his home oxygen up wide open. Despite this, however, he re-
mained severely short of breath. His wife then called 911 and he was brought to the ER via ambulance.

The patient denies substernal chest pain. He states that he has gained approximately five pounds over the past
couple of weeks. He also admits to swelling of both ankles at the end of the day.

PAST MEDICAL HISTORY: Several episodes of COPD in the past. He has also been admitted with MI’s
at age 66 and again in September, three years ago. He has had congestive heart failure and long-standing
insulin-dependent diabetes mellitus. He has glaucoma and chronic blindness in his right eye. He has a history of
long-standing noncardiac chest pain. He has also had peptic ulcer disease.

PAST SURGICAL HISTORY: He is status post T&A, hemorrhoidectomy x 2, colonoscopy with


polypectomy in six years ago which revealed a tubular adenoma, right inguinal herniorrhaphy four years ago,
another colonoscopy repeated three years ago. He had a TURP in 1981 for benign prostatic hypertrophy.

MEDICATIONS: Humulin N 64 units in the morning and 64 units in the evening. Humalog sliding scale t.i.d.,
usually taking 14 to 16 units at mealtimes. He also takes Theo-Dur 200 mg b.i.d., Lasix 160 mg a.m. and 80
mg at noon q.d. Ecotrin 325 mg q.d. Pilocarpine 4% ophthalmic drops 1 drop right eye q.i.d., Imdur 60 mg
q.h.s., Diazepam 10 mg q.h.s., Clorazepate 15 mg q.h.s., nitroglycerin 0.4 mg sublingual p.r.n. chest pain,
albuterol and Atrovent nebulizer q.i.d. and p.r.n. He is on home O2 routinely at 2 liters per minute per nasal
cannula.

ALLERGIES: Penicillin causes a rash.

HABITS: 150 pack year history of cigarette smoking. He is currently a nonsmoker, does not drink alcohol.

FAMILY HISTORY: The patient is married and is a retired teacher. He lives in Podunk Center with his wife
who also has had some health problems, including atrial fibrillation. They have three children in the area.

REVIEW OF SYSTEMS:
General: No seizures or syncope. He has had the weight gain as mentioned above.
HEENT: No recent change in hearing or vision. He does have the glaucoma as mentioned above.
Dr.
Signature

Form 9427 (8/00) mr HISTORY & PHYSICAL


© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems Newman, Edward C.
Painted Valley, USA Dr. William J. Wainwright
Coronary care unit
# 012502

Respiratory: As above.
Cardiac: See HPI.
GI: No nausea, vomiting, diarrhea, constipation, hematochezia or melena.
GU: No burning, hematuria or recent UTI. He states that he does have nocturia one to two times per night.
Musculoskeletal: Negative.
Neurologic: He has been depressed over his breathing difficulties.

PHYSICAL EXAMINATION:
General: This is a well-developed, well-nourished 78-year-old white male, sitting up on the examining table
with oxygen running. He appears in no acute distress at this time.
Vital Signs: Blood pressure 144/72, pulse 108, respirations 38, temperature 96.4 degrees Fahrenheit. Weight
190 pounds.
Skin: Anicteric, warm and dry. Face is slightly flushed at this time.
Heent: Shows clear TMs. Pupils equal, round and reactive to light on the left. There is evidence of corneal
dystrophy on the right. Oropharynx is clear.
Neck: Supple, no cervical lymphadenopathy.
Chest: Lungs have slight crackles in the right mid-lung field and base, clear on the left.
Heart: Regular rate and rhythm without murmur or gallop.
Abdomen: Normal bowel sounds, soft and nontender. No masses, hernias or organomegaly noted.
Genitalia: External genitalia is normal.
Extremities: Warm and well perfused. There is trace edema bilaterally. Pedal pulses are palpable.
Neurologic: Motor and strength are 5/5 bilaterally. DTRs are symmetrical.
Psych: Affect is more flat than typically seen. Recent and remote memory are good. Judgement and insight
are intact. Does seem to be slightly depressed.

LABS: Chest x-ray shows cardiomegaly and evidence of vascular redistribution consistent with CHF. EKG
shows normal sinus rhythm at a rate of 94 beats per minute. There is evidence of an old anterior MI and an old
inferior MI. No acute appearing ST-T wave changes. Sodium is 143, potassium 4.4, BUN 27, creatinine 1.5,
glucose 238. CBC shows white count 10,400 with a normal differential, hemoglobin 13.6, hematocrit 37.9.

ASSESSMENT:
1. A 78-year-old white male with cor pulmonale and congestive heart failure secondary to his severe
chronic obstructive pulmonary disease and coronary artery disease.
2. Arteriosclerotic heart disease with history of previous myocardial infarctions and congestive heart failure.
3. Chronic glaucoma with right eye blindness.
4. Chronic insomnia.
5. Insulin-dependent diabetes mellitus.
6. Benign prostatic hypertrophy, status post transurethral resection of prostate.

PLAN: The patient will be admitted to the CCU. Monitor his O2 saturations, provide oxygen as necessary
and diurese him.
Dr. William J. Wainwright
Signature
D&T: 8/14/xx
Form 9427 (8/00) mr HISTORY & PHYSICAL
© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems
Painted Valley, USA Newman, Edward C.
Dr. Dr. William J. Wainwright
Coronary care unit
# 012502
Date 08/14
_____________ 08/15
_____________ 08/16
_____________ _____________
Time 3 6 9 12 15 18 21 24 3 6 9 12 15 18 21 24 3 6 9 12 15 18 21 24 3 6 9 12 15 18 21 24

105 ...................................................................................................................................................

104 ...................................................................................................................................................

103 ...................................................................................................................................................

102 ...................................................................................................................................................

101 ...................................................................................................................................................

100 ...................................................................................................................................................

99 ...................................................................................................................................................

98 ...................................................................................................................................................

97 ...................................................................................................................................................

96 ...................................................................................................................................................

95 ...................................................................................................................................................

Pulse 93 102 89 88 86 76

Resp. 38 20 21 24 20 18

B/P 143 72 144


___/___| 62 136
___/___| 74 ___/___|
___/___ 140 78 ___/___|
110 60 122 76 122 78 ___/___| ___/___ ___/___| ___/___| ___/___
___/______/___|
___/___| ___/___| ___/___ ___/___| ___/___| ___/______/___| ___/___| ___/___ ___/___| ___/___| ___/___

In ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______
Out ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______

Weight: 195.7
______ 194.9
| _______ 193.3
______ 192.6
| _______ 190.4 | _______
______ ______ | _______

ADA ______
Diet ______| ______| ADA ADA ______|
______| ADA ADA______ ADA ______| ______
______| ______| ______| ______
Appetite ______|Good ______
______| Fair Fair
______| Good Good
______| ______ Fair
______| ______| ______ ______| ______| ______

GRAPHIC SHEET
© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems
Painted Valley, USA
Patient's Name Street Address Hospital Number
Newman, Edward C. 2720 Mountain View # 012502
Birth Date Age City Phone Number
04/01/xx 78 Devils Lake 701 801-7734
Sex Marital Status State Zip County Room
M Married N.D. 58301 Ramsey CCU #2
Soc. Sec. # Religion Race
504-59-3132 Methodist W
Patient's Occupation Ethnicity
Teacher (Retired) Non-Hispanic
Notify In Name Relationship Responsible for Account
Emergency Mildred Wife Self
Address Phone No.
2720 Mountain View, Devils Lake 701 801-7734
Date Admitted Time AM Date Discharged Time AM
8/14/xx 0645 PM 08/16/xx 1111 PM
Date of Last Admission Name & Address of Any Institution From Which Discharged in Last 60 Days
2/29/xx N/A
Admitting Physician Consultant
Dr. William J. Wainwright
Aitemding Physician
Dr. William J. Wainwright

Admitting Diagnosis (Within 24 Hours) ICD-9-CM CODES

Cor pulmonale and congestive heart failure secondary to severe chronic obstructive
pulmonary disease and coronary artery disease.
Principal Diagnosis

1. Congestive heart failure complicating severe chronic obstructive pulmonary disease.

Secondary Diagnoses

2. Arteriosclerotic heart disease with history of myocardial infarctions.


3. Insulin-dependent diabetes mellitus.
4. Glaucoma.
Complications

Operative Procedures (Date & Title)

Discharged Alive ____ ü Died ____ Autopsy Yes ____ No ____

William J. Wainwright Physician Signature

ADMISSION SUMMARY SHEET


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.
CONDITIONS OF ADMISSION

1. CONSENT TO HOSPITAL CARE


I am presenting myself for admission to St. Jude’s Medical Center. 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 St. Jude’s Medical Center 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 St. Jude’s Medical Center, 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 St. Jude’s Medical Center 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


ü 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


ü NO

This document has been fully explained to me, and I certify that I understand its contents and agree to it freely.

August 14, xx 0645 AM


Edward C. Newman
DATE TIME PM Patient or authorized person
Marilyn Flemming
Witness Relationship

Guarantor/Insured Certificate Holder

Signature is not that of the patient because: ( ) patient is a minor

( ) other reason (specify):


Sundance HealthCare Systems
Painted Valley, USA
Patient's Name Street Address Hospital Number

Birth Date Age City Phone Number

Sex Marital Status State Zip County Room

Soc. Sec. # Religion Race

Patient's Occupation Ethnicity

Notify In Name Relationship Responsible for Account


Emergency
Address Phone No.

Date Admitted Time AM Date Discharged Time AM


PM PM
Date of Last Admission Name & Address of Any Institution From Which Discharged in Last 60 Days

Admitting Physician Consultant

Aitemding Physician

Admitting Diagnosis (Within 24 Hours) ICD-9-CM CODES

Principal Diagnosis

Secondary Diagnoses

Complications

Operative Procedures (Date & Title)

Discharged Alive ____ Died ____ Autopsy Yes ____ No ____

Physician Signature

ADMISSION SUMMARY SHEET


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.
Sundance HealthCare Systems
EMERGENCY ROOM / OUTPATIENT RECORD
Painted Valley, USA Account Number:

Patient's Name: Last Name First Name Middle Initial Home Phone Admission Date a.m. Med.Rec. Number
Newman, Edward C. 701 801-7734 08/14 p.m. # 012502
Address: State Zip Age Sex Date of Birth Civil Status Religion
Devils Lake N.D. 58301 78 M 04/01 S M W D Sep Methodist
Employer: Retired Occupation: Teacher Soc. Sec. # 504-59-3132
Address: Tokyo, ND Phone No: Notify Press Yes No
Responsible Party: Alfred E. Newman Occupation: Teacher Family Doctor: Dr. Wainwright
Address: Devils Lake, ND Phone No: 801-7734 Notified Yes No
Brought In By: xx
___ Self
Name of Insurance Company Medicare Policy No. AP 504-39-3132 ___ Police ___ Fire
Address of Insurance Co. Hooterville, ND ___ Relative ___ Other
Notified: Relative Mildred Relationiship: Wife By Whom Agathie Chrsty Race:

Police No Coroner No Time 0645 a.m./p.m. Ethnicity:

BRIEF HISTORY: (If accident, state where, when & how injured; if illness describe)
:

78-year-old male to ER per ambulance. Awoke at 0600 with acute respiratory distress. Hx COPD. Did home nebulizers
without relief. Ambulance called for transport. Second neb started et finished en route. Accu ü done also “200”. Currently
mildly dyspneic, respirations 38, lungs slightly et moderate diminished. SAO2 98% on 2 liter p.m. NC. ??? Rhythm NS without
ectopics. 0725 Saline lock 22 g 28 mm Jelco started L hand - Lasix 80 mg IV push. Lock flushed per protocol NUB.
0730 Dr. Wainwright in to examine patient.
0740 Admit Coronary care unit .
0810 Patient to floor in W/C per RN
Allergies: Penicillin Patient Medications: See attached sheet.
Condition on Admission:
PHYSICIAN'S REPORT: History & Physical Findings:
Good ____ Fair xx
____ Increasing shortness of breath 6:00 a.m. No chest pain. No cough. Has been on
Poor ____ Shock ____
home O2. O2 sat on 2LNC 96% Pulse increased,
Coma ____ Hemorrhage ____
Vital Signs: Adm H: CHF RR 28 pm
Temp. 96.4
____ Height: 72" ASHD Heart: WNL.
Pulse 108
____ Weight: 190 Diagnosis: Lungs: Expiratory wheezes bilaterally.
Resp. 48
____ SAO2 96%
B.P. 143 72
____/____ Lower extremity edema 1+.
Normal Other System Inventory: Treatment (including medications):

o o Mental/Emotional
o o Status:

ü
o o Skin Disposition of Case: Admitted to CCU, LAB: CXR, EKG, CBC, PO2 (Theo Old charts
o ü
o Respiratory per Dr. Wainright / Ries RN) A: Acute exacerbation of asthma / LVF.
ü
o o Cardiovascular. Referred to Dr. Lasix 20 mg IV Date:
ü
o o Musculoskeletal: Instructions to Patient: P: Admit to CCU.
ü
o o Gastrointestinal
ü
o o Genitourinary
ü
o o Neurological
ü
o o EENT Edward C. Newman 8/14/xx 6:45 William J. Wainwright
Form # _ _ _ _ Patient's Signature Date Time Attending Physician
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
PATIENT:

A.M.
DATE: DATE: P.M.

1. I, (or ) acting for )

knowing that I, (or ) am (is) suffering from a condition requiring emergency or out patient care do hereby
voluntarily consent to such care encompassing diagnostic procedures and medical treatment by Dr.
his assistants or his designees as is necessary in his judgement.

2. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as to the result
of treatments or examination in the hospital.

3. This form has been fully explained to me and I certify that I understand its contents.

Witness Signature of Patient

(If patient is unable to consent or is a minor, complete the following):


Patient (is a minor years of age) is unable to consent because

Witness Closest Relative or Legal Guardian

Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems
EMERGENCY ROOM / OUTPATIENT RECORD
Painted Valley, USA Account Number:

Patient's Name: Last Name First Name Middle Initial Home Phone Admission Date a.m. Med.Rec. Number
p.m.

Address: State Zip Age Sex Date of Birth Civil Status Religion
S M W D Sep
Employer: Occupation: Soc. Sec. #
Address: Phone No: Notify Press Yes No
Responsible Party: Occupation: Family Doctor:
Address: Phone No: Notified Yes No
Brought In By: ___ Self
Name of Insurance Company Policy No. ___ Police ___ Fire
Address of Insurance Co. ___ Relative ___ Other
Notified: Relative Relationiship: By Whom Race:

Police Coroner Time a.m./p.m. Ethnicity:

BRIEF HISTORY: (If accident, state where, when & how injured; if illness describe)
:

Condition on Admission:
PHYSICIAN'S REPORT: History & Physical Findings:
Good ____ Fair ____
Poor ____ Shock ____
Coma ____ Hemorrhage ____
Vital Signs:
Temp. ____
Pulse ____ Diagnosis:
Resp. ____
B.P. ____/____
Normal Other System Inventory: Treatment (including medications):

o o Mental/Emotional
o o Status:

o o Skin Disposition of Case:

o o Respiratory

o o Cardiovascular. Referred to Dr. Date:

o o Musculoskeletal: Instructions to Patient:

o o Gastrointestinal

o o Genitourinary

o o Neurological

o o EENT
Form # _ _ _ _ Patient's Signature Date Time Attending Physician
Simulated record. ©2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems
Painted Valley, USA

NEWMAN, Edward C. # 012502

Age 78 CCU

Dr. D. J. Wagner 8-14-xx a.m.

MECHANISM: Normal sinus rhythm

RATE: 94 beats per minute

AXIS Left axis deviation. P-R-T axes 68 - 55 116

PW: Are broadened. P-R interval 162 ms

COMPLEXES: Normal voltage. Left ventricular hypertrophy with QRS widening. Left atrial
enlargement. QT/Qtc 317/398 ms. QRS interval is 118 ms.

TW: Nonspecific ST and T-wave abnormality.

COMMENT: Abnormal EKG, possible lateral ischemia. Old anterior MI. No change from
previous EKG.

DJW/bg
St. Luke’s
D&T: 8-14-xx

Donald J. Wagner
Cardiologist Signature

Form 4101 (10/01) mr ELECTRCARDIOGRAM


© 2003. American Health Information Management Association. All rights reserved.
Sundance HealthCare Systems
Painted Valley, USA NEWMAN, Edward C.
Dr. William J. Wainwright
Coronary care unit
# 012502

DISCHARGE SUMMARY:

This patient is a 78-year-old gentleman from Podunk Center. He was admitted because of increasing problems
associated with his chronic congestive heart failure, COPD, diabetes and ASHD. The patient was experiencing
increasing dyspnea associated with the CHF. He was given an IV and increased dose of Lasix. Following this
the patient diuresed approximately five pounds during his hospitalization. Both his O2 saturations and breathing
steadily improved.

Two days after admission he was feeling much better. He had been up walking and was having no chest pain.

He is being discharged in improved condition.

DISCHARGE MEDICATIONS:
Diazepam 20 mg p.o. q.h.s., albuterol and Atrovent nebulizers q.i.d. and p.r.n., Lasix 160 mg p.o. b.i.d.; Theo-
Dur 200 mg q.a.m., 300 mg q.h.s.; Imdur 30 mg (1/2 tab) q.h.s., Pilocarpine 4% 1 drop O.D. q.i.d., nitroglyc-
erin 0.4 mg sublingual p.r.n. chest pain, oxygen 2 to 4 liters per minute per nasal cannula. For his diabetes he
will be on Humulin N 64 U a.m., Humulin N 36 U p.m. and Humalog sliding scale as follows:
Accu-Chek less than 100 = 0,
Accu-Chek 101 - 130 = 3,
Accu-Chek 131 - 170 = 5,
Accu-Chek 171 - 220 = 8,
Accu-Chek 221 - 300 = 12,
Accu-Chek 301 - 400 = 15,
Accu-Chek more than 400 = 18.

FOLLOW-UP: Mr. Newman has an appointment to see me in the office in approximately two weeks for
recheck. He should call or come in sooner if he has any questions or problems prior to that appointment. He is
to check his weights on a daily basis at home and if he gains more than two pounds from his discharge weight he
is to call me at once or come into the ER or walk-in clinic.

FINAL DIAGNOSIS:
1. Congestive heart failure complicating severe chronic obstructive pulmonary disease.
2. Arteriosclerotic heart disease with history of myocardial infarctions.
3. Insulin-dependent diabetes mellitus.
4. Glaucoma.

PROCEDURES: None.

COMPLICATIONS: None.

DJW/sgs
D&T: 8/16/xx William J. Wainwright
Form 9055 (3/98) him DISCHARGE SUMMARY
© 2003. American Health Information Management Association. All rights reserved.