HIM 200 Health Record

Note: Permission to reuse granted by Alfred State College and Michelle A.
Green
Global Care Medical Center
100 Main St, Alfred NY 14802 INPATIENT FACE SHEET

(607) 555-1234
Hospital No. 999
Patient Name and Address Gender Race Marital Status Patient No.
F W S IPCase003
RAY, PAM
380 HOWE ROAD Date of Birth Age Maiden Name Occupation
ALMOND, NY 14804 02/08/YYYY 63 NA Cleaner

Admission Date Time Discharge Date Time Length of Stay Telephone Number
04/18/YYYY 1253 04/20/YYYY 1150 02 DAYS (607)555-3319
Guarantor Name and Address Next Of Kin Name and Address
RAY, PAM RAY, MATT

380 HOWE ROAD 380 HOWE ROAD
ALMOND, NY 14804 ALMOND, NY 1480
Guarantor Telephone No. Relationship to Patient Next of Kin Telephone Number Relationship to Patient
(607)555-3319 (607)555-3319 Brother
Admitting Physician Service Admit Type Room Number/Bed
Harold Dunn, MD
Attending Physician Admitting Diagnosis
Harold Dunn, MD Advanced periodontal disease and infected teeth
Primary Insurer Policy and Group Number Secondary Insurer Policy and Group Number
NA NA NA NA
Diagnoses and Procedures ICD Code
Principal Diagnosis
Diseased and carious mandibular teeth.

Secondary Diagnoses
Thrombocyotopenic purpura.
Congestive heart failure.
Cirrhosis.
Arteriosclerotic heart disease.
Chronic alcoholism.
Principal Procedure
Extraction of 6 mandibular teeth. Mandibular alveolectomy.

Secondary Procedures
Discharge Instructions
Activity: ❒ Bed rest ❒ Light ❒ Usual ❒ Unlimited ❒ Other:
Diet: ❒ Regular ❒ Low Cholesterol ❒ Low Salt ❒ ADA ❒ Calorie
Follow-Up: © Call for appointment ❒ Office appointment on ❒ Other: To be seen for a follow up
in office in one week
Special Instructions: None
Attending Physician Authentication:
RAY, PAM Admission: 04/18/YYYY CONSENT TO ADMISSION
IPCase003 DOB: 02/08/YYYY
Dr. DUNN ROOM: 244
I, Pam Ray 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: Pam Ray ATP-B-S:02:1001261385:
Pam Ray
(Signed:)
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: 4/18/YYYY 2:12:05 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.
Signature of Patient
Signature of Parent/Legal Guardian for Minor
Relationship to Minor
WITNESS: Global Care Medical Center Staff Member
GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234
JONES, SARA Admission: 04/18/YYYY
ADVANCE DIRECTIVE
Dr. DUNN ROOM: 244
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 X
“Patient Rights Regarding Health Care Decision?”
2. Have you prepared a “Living Will?” If yes, please provide the X
Hospital with a copy for your medical record.
3. Have you prepared a Durable Power of Attorney for Health Care? X
If yes, please provide the Hospital with a copy for your medical
record.
4. Have you provided this facility with an Advance Directive on a X
prior admission and is it still in effect? If yes, Admitting Office to
contact Medical Records to obtain a copy for the medical record.
5. Do you desire to execute a Living Will/Durable Power of X
Attorney? If yes, refer to in order: a.
Physician
b. Social Service
c. Volunteer Service
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: Pam Ray
ATP-B-S:02:1001261385: Pam Ray
(Signed: 4/18/YYYY 2:35:05 PM EST)
Signature of Patient Date
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
Signature of Hospital Representative Date
RAY, PAM Admission: 04/18/YYYY
DISCHARGE SUMMARY
Dr. DUNN ROOM: 244
ADMISSION DATE: 04/18/YYYY
DISCHARGE DATE: 04/20/YYYY ADMISSION DIAGNOSIS: Diseased
and carious mandibular teeth.
DISCHARGE DIAGNOSIS: Same, plus hypertrophied alveolar process, congestive heart failure,
thrombocytopenic purpura, cirrhosis, arteriosclerotic heart disease, and chronic
alcoholism.
OPERATION: Extraction of 6 mandibular teeth, mandibular

alveolectomy. SURGEON: Dunn DATE: 04/19/YYYY COMPLICATIONS: None.
SUMMARY: Pam Ray was admitted to the hospital for removal of her six abscessed mandibular
teeth under general anesthesia. She had hypertrophied alveolar process, and she was very
medically compromised because of CHF, thrombocytopenic purpura, cirrhosis, and ASHD.
Medications for CHF, thrombocytopenic purpura, cirrhosis, and ASHD were continued during
her inpatient stay.
Electrocardiogram showed nonspecific ST segment changes. Her urinalysis was normal. Her PTT and prothrombin times were normal. Hemoglobin 13.5 grams %, hematocrit
40 volume % and white count 6,800 with 30 segmented cells, 51 lymphocytes, 14 monocytes, 3 eosinophils and 2 basophils.
She tolerated her surgery well. She had sutures put in her gum. She had significant swelling of her mandible area and lip. She also complained of pains in the left lower
quadrant but no diarrhea and no guarding or rigidity and no elevation of the white count, so no further studies were done at this time. She was kept overnight because of her
medically compromised conditions. She is being discharged now to continue her Lasix and Lanoxin, and she will be seen in the office in three days for follow up care.
DD: 04/20/YYYY
DT: 04/21/YYYY Physician Name
HISTORY & PHYSICAL EXAM
Dr. DUNN ROOM: 244
4/18/YYYY
ADMITTING DIAGNOSIS:
HISTORY PRESENT ILLNESS: Pam Ray has been having pain, discomfort and bleeding from her
mandible where a bridge has been attached to her few remaining lower teeth. This has been
quite bothersome through several months and she has been seeing her dentist but a
solution has not been easily attained and she was seen in the office here. I referred her
to Dr. Black for reevaluation and he plans to remove her teeth under general anesthesia.
PAST MEDICAL HISTORY: Significant in that she had thrombocytopenic purpura many years ago
and had a splenectomy. She has had no significant bleeding problems since that time but
has been avoiding all Salicylates and many medications for fear they may cause bleeding.
She has had two hernia repairs however without difficulty and she also has a history of
heavy alcohol ingestion through the years up until about January YYYY and she maintains
that she now is not drinking at all and I have no reason to doubt her statement.
FAMILY HISTORY: No known diabetes, heart disease or tuberculosis. SOCIAL HISTORY: She is
employed at a local plant nursery and does some cleaning and maintenance work. She does
not smoke and participates in AA for chronic alcoholism.
REVIEW OF SYSTEMS: Cardiorespiratory system: No chest pain, no cough or cold, no ankle

swelling or edema, though she has had congestive failure with leg and ankle swelling in
the past. Gastrointestinal system: She is very slim but has had no recent weight change.
Her bowel movements have been normal. She has no specific food intolerances.
Genitourinary system: No frequency or burning with urination. Musculoskeletal system: She
complains of some numbness and paresthesias in her legs and hands that is of an
intermittent and erratic nature.
GENERAL: Thin, elderly white female in moderate distress with pain in her mandible and
around her lower teeth. VITAL SIGNS: Temperature 98, pulse 74, respirations 16, blood
pressure 154/90.
EENT: Eyes: Pupils round, regular and equal; react to light and accommodation. Ears, Nose
and Throat: Normal. Teeth: Lower remaining mandibular teeth in poor repair and gingivitis
is present. NECK: Supple, thyroid is not enlarged, no carotid bruits.
HEART: Normal sinus rhythm, no murmurs. LUNGS: Clear to auscultation and percussion.
BREASTS: Soft and atrophic with no masses palpable.
ABDOMEN: Soft, liver and kidneys are not enlarged; splenectomy scar as noted. Peristalsis
is normal.
EXTERNAL GENITALIA: Normal.
EXTREMITIES: No edema; the peripheral pulses are decreased but present bilaterally, no
edema is present at this time. No objective motor or sensory deficit is elicited.
DD: 04/18/YYYY Reviewed and Approved: Harold Dunn MD

ATP-B-S:02:1001261385: Harold Dunn MD
GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234
CONSULTATION REPORT
Dr. DUNN ROOM: 244
S. Anderson, DPM
Dr. Black asked me to see Ms. Ray since I was to see her on Friday morning
in my office for follow up of a removal of an infected ingrown toenail and
drainage of the abscess that was present. This was on her right great toe.
I evaluated the toe today. There is a small eschar present. The toe is
healing very well. The patient does complain of some tenderness yet present
in the toe. This would be likely with the process which was present the
infection and the abscess in that border. The nail was significantly
ingrown and as noted this would be the reason for some discomfort yet. As
noted above, the op site is healing very well and I told her that she
should contact me as needed.
Thank you very much for the opportunity to see Ms. Ray.
DD: 04/20/YYYY Reviewed and Approved: S. Anderson DPM

ATP-B-S:02:1001261385: S. Anderson DPM
PROGRESS NOTES
Dr. DUNN ROOM: 244
Date Time
Physician’s signature required for each order. (Please skip one line between dates.)
04/18/YYYY 1352 CHIEF COMPLAINT: Jaw pain. DIAGNOSIS: Diseased teeth

and gums. History of thrombocytopenic purpura with
splenectomy. History of alcoholism. History of
congestive heart failure. PLAN OF TREATMENT: Dental
extractions. Confirmed X Provisional .
DISCHARGE PLAN: Home. No services needed.
04/18/YYYY 2100 Pre-Op Care: 2125

63 year old female Plan general anesthesia Physical
exam pending.
Reviewed and Approved: Jon Black DDS ATP-B-

S:02:1001261385: Jon Black DDS
04/19/YYYY 1000 General anesthesia. 6 extractions and alveolectomy. To

Recovery Room in good condition.

(Signed: 4/19/YYYY 10:03:30 AM EST)
04/19/YYYY 1200 Recovery uneventful. Appointment given for 04/24

Prescription: Tylenol #2 x 10 1 every four hours as
needed. Discharge diagnosis: infected teeth;
hypertrophied alveolar process. Greatly medically
compromised patient.

04/19/YYYY Podiatry: recovering from infected ingrown toenail

right – 1 medial border. Healing very well. Advised to
contact me as needed. Thank you!
GLOBAL MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234
DOCTORS' ORDERS
Dr. DUNN ROOM: 244
Date Time Physician’s signature required for each order. (Please skip one line between dates.)
04/18/YYYY 1000 1) Admit service Dr. Dunn, Black

2) Chest X-Ray (done 04/18/YYYY)
3) Electrocardiogram
4) complete blood count, urinalysis, Protime, PTT

5) Dr. Dunn for history and physical and medical orders
6) Regular diet – nothing by mouth after midnight
7) Dalmane 30 milligrams. by mouth at bedtime
8) Robinul 0.2 milligrams intramuscular 1° pre op
9) Vistaril 50 milligrams intramuscular 1° pre op

1200 History and physical dictated. OK general anesthesia.

Lanolin 0.125 by mouth daily.
Reviewed and Approved: Harold Dunn MD

ATP-B-S:02:1001261385: Harold Dunn MD
Lasix 40 milligrams by mouth daily. Codeine with Tylenol

½ grain by mouth 4 times a day as needed for pain or
Tylenol #3.
Reviewed and Approved: Harold Dunn MD ATP-B-

S:02:1001261385: Harold Dunn MD
04/19/YYYY 0700 Call Dr. Anderson to see patient today.

1000 1) Ice to chin

2) Remove oral pack in Recovery Room
3) Liquid diet
4) Dr. Dunn for medical orders
5) Tylenol #2 by mouth every 4 hours as needed
6) Discharged from Recovery Room at 1055

DOCTORS' ORDERS
Dr. DUNN ROOM: 244
Date Time Physician’s signature required for each order. (Please skip one line between dates.)
04/19/YYYY 1100 Resume:

Lanoxin 0.125 milligrams daily start today
Lasix 40 milligrams daily start today

04/19/YYYY 1200 Discharge tomorrow at discretion of Dr. Dunn

To report to my office 04/24

04/19/YYYY 1230 Nubain 10 milligram intramuscular now

04/19/YYYY 1800 Dalmane 30 milligrams by mouth at bedtime

04/20/YYYY 0700 Discharge

LABORATORY DATA
Dr. DUNN ROOM: 244
SPECIMEN COLLECTED: 04/18/YYYY 1315 SPECIMEN RECEIVED: 04/18/YYYY 1402
HEMATOLOGY II
3
PLATELET COUNT NORMAL 130-400 X 10
BLEEDING TIME NORMAL 1-4 MINUTES Pt: SEC.
X PROTIME CONTROL: 12.5 SEC. Pt: 12.8 SEC.
X PTT NORMAL: <32 SEC. Pt: 22 SEC.
FIBRINDEX CONTROL: Pt:
FIBRINOGEN NORMAL: Pt: F.D.P. NORMAL: Pt:
CLOT RETRACTION NORMAL 30-65% Pt: %
CLOT LYSIS 24hr: 48 hr:
COMMENTS:
***End of Report***
RAY, PAM Admission: 04/18/YYYY LABORATORY DATA
Dr. DUNN ROOM: 244
TIME IN: 04/18/YYYY 1315 TIME OUT: 04/14/YYYY 1503
CBC S DIFFERENTIAL
TEST RESULT FLAG REFERENCE
WBC 6.8 4.5-11.0 thous/UL

RBC 4.22 5.2-5.4 mill/UL
HGB 13.5 11.7-16.1 g/dl
HCT 39.6 35.0-47.0 % MCV 93.9 85-99 fL.
MCH 32.1
MCHC 34.2 33-37
RDW 11.4-14.5
PTL 135. 130-400 thous/UL

SEGS % 30
LYMPH % 51 20.5-51.1
MONO % 14 1.7-9.3
EOS % 3
BASO % 2
BAND %
GRAN % 42.2-75.2
LYMPH x 103 1.2-3.4
MONO x 103 0.11-0.59
GRAN x 103 1.4-6.5
EOS x 103 0.0-0.7
BASO x 103 0.0-0.2
ANISO
***End of Report***
LABORATORY DATA
Dr. DUNN ROOM: 244
SPECIMEN COLLECTED: 04/18/YYYY 1315 SPECIMEN RECEIVED: 04/18/YYYY 1341
URINALYSIS
TEST RESULT FLAG REFERENCE
DIPSTICK ONLY
COLOR Straw
Ph. 6.5 5-8.0

SP. GR. 1.011  1.030
ALBUMIN Neg
SUGAR Neg  10 mg/dl

ACETONE Neg
BILIRUBIN Neg  0.8 mg/dl

BLOOD Neg 0.06 mg/dl hgb
REDUCING  -1 mg/dl
EPITH: 2+
W.B.C.: Occasional  5/hpf

R.B.C.: -  5/hpf
BACT.: Few 1+( 20/hpf)
CASTS.: -
CRYSTALS: -
***End of Report***
RAY, PAM Admission: 04/18/YYYY CONSENT FOR OPERATION(S) ANDIOR
IPCase003 DOB: 02/08/YYYY PROCEDURE(S) AND ANESTHESIA
Dr. DUNN ROOM: 244
PERMISSION. I hereby authorize Dr. Dunn , or associates of his/her choice at the
Global Center (the “Hospital”) to perform upon Pam Ray

the
following operation(s) and/or procedure(s): Extraction of 6 mandibular teeth, mandibular alveolectomy
including such photography, videotaping, televising or other observation of the operation(s)/procedure(s) as may be purposeful for the
advance of medical knowledge and/or education, with the understanding that the patient’s identity will remain anonymous.
EXPLANATION OF PROCEDURE, RISKS, BENEFITS, ALTERNATIVES. Dr.

Dunn
has fully explained to me the nature and purposes of the operation(s)/procedures named above and has also informed me of expected benefits
and complications, attendant discomforts and risks that may arise, as well as possible alternatives to the proposed treatment. I have been given
an opportunity to ask questions and all my questions have been answered fully and satisfactorily.
UNFORESEEN CONDITIONS. I understand that during the course of the operation(s) or procedure(s), unforeseen conditions may arise
which necessitate procedures in addition to or different from those contemplated. I, therefore, consent to the performance of additional
operations and procedures which the above-named physician or his/her associates or assistants may consider necessary.
ANESTHESIA. I further consent to the administration of such anesthesia as may be considered necessary by the above-named physician or
his/her associates or assistants. I recognize that there are always risks to life and health associated with anesthesia. Such risks have been
fully explained to me and I have been given an opportunity to ask questions and all my questions have been answered fully and
satisfactorily.
SPECIMENS. Any organs or tissues surgically removed may be examined and retained by the Hospital for medical, scientific or
educational purposes and such tissues or parts may be disposed of in accordance with accustomed practice and applicable State laws and/or
regulations.
NO GUARANTEES. I acknowledge that no guarantees or assurances have been made to me concerning the operation(s) or procedure(s)
described above.
MEDICAL DEVICE TRACKING. I hereby authorize the release of my Social Security number to the manufacturer of the medical
device(s) I receive, if applicable, in accordance with federal law and regulations which may be used to help locate me if a need arises with
regard to this medical device. I release The Global Medical Center from any liability that might result from the release of this information.*
UNDERSTANDING OF THIS FORM. I confirm that I have read this form, fully understand its contents, and that all blank spaces
above have been completed prior to my signing. I have crossed out any paragraphs above that do not pertain to me.
Patient/Relative/Guardian* ATP-B-S:02:1001261385: Pam Ray Pam Ray
Signature Print Name
Relationship, if other than patient signed:
Reviewed and Approved: William Preston

Witness:
ATP-B-S:02:1001261385: William Preston William Preston
Signature Print Name
Date: 04/18/YYYY
*The signature of the patient must be obtained unless the patient is an unemancipated minor under the age of 18 or is otherwise incompetent
to sign.
PHYSICIAN’S CERTIFICATION. I hereby certify that I have explained the nature, purpose, benefits, risks of and alternatives to the
operation(s)/ procedure(s), have offered to answer any questions and have fully answered all such questions. I believe that the patient
(relative/guardian) fully understands what I have explained and answered.
Reviewed and Approved: Harold Dunn MD
PHYSICIAN: ATP-B-S:02:1001261385: Harold Dunn MD §[‡(Ø‡{{{{
Signature Date
OPERATIVE REPORT
Dr. DUNN ROOM: 244
PREOPERATIVE DIAGNOSIS: 6 abscessed mandibular teeth, hypertrophied

alveolar process, extremely medically compromised patient.
POSTOPERATIVE DIAGNOSIS: 6 infected mandibular teeth, hypertrophied

mandibular alveolar process.
OPERATIION PERFORMED: Extraction of 6 mandibular teeth, mandibular

alveolectomy.
SURGEON: Black ASSISTANT: DATE: 04/19/YYYY

ANESTHESIA: General and Xylocaine infiltration.
OPERATIVE NOTE: Following induction of general anesthesia the buccal
sulcus was infiltrated with Lidocaine anesthesia. Approximately 2 cc. of
Lidocaine 1% was used. The remaining 6 teeth were then removed with
forceps and the mucoperiosteal flap was made exposing alveolar process.
This was trimmed with rongeurs and filed smooth with bone file. The tissue
flaps were then trimmed with scissors, approximated and closed with
blanket 3-0 silk suture. Minimal bleeding occurred during the procedure.
The patient was then recovered and returned to the Recovery Room in good
condition with 1 oral pack in place.
DD: 04/20/YYYY Reviewed and Approved: Jon Black DDS

ATP-B-S:02:1001261385: Jon Black DDS
PATHOLOGY REPORT
Dr. DUNN ROOM: 244
Date of Surgery: 04/19/YYYY
OPERATION: Extraction of teeth.
SPECIMEN: teeth
GROSS: The specimen consists of 6 teeth.
GROSS DIAGNOSIS ONLY: TEETH (6)
DD:4/20/YYYY Reviewed and Approved: Marc Reynolds, Pathologist

ATP-B-S:02:1001261385: Marc Reynolds, Pathologist
DT:4/20/YYYY
IPCase003 DOB: 02/08/YYYY RECOVERY ROOM RECORD

Dr. DUNN ROOM: 244
0 15 30 45 60 15 30 45 60 Date: 04-19/YYYY Time: 0955

230 Operation: extraction
220 Anesthesia: General
210 Airway: N/A
200 O2 Used: □Yes © No
190 Route:
180 Time Medications Site

170
160
150
140 Y Y Y Y Y Y
130 Y Y Y Y Intake Amount

120 650 cc D5L R Left hand
◆ ◆ ◆ ◆ ◆ ◆
110 ^ ^ ^ ^ IV discontinued at 1050

◆ ◆ ◆ ◆
100 ^ ^ ^ ^ ^ ^ Needle out intact
90 Total 50 cc
80
70 Output Amount
60 Catheter N/A
50 Levine N/A
40 Hemovac N/A
30 Ç@ £
Total
20 § § § § § § § § § §
10 Discharge Status
0 Room: 0244 Time: 1055
 hermoscan probe. Oral mode q9 adm. Condition: Satisfactory
PostAnesthesia Recovery Score Adm 30 min 1 hr 2 hr Disch
Transferred by Stretcher
Moves 4 extremities voluntarily or on command (2)
Moves 2 extremities voluntarily or on command (1)
R.R. Nurse:
Moves 0 extremities voluntarily or on command (0) Rev& App: Mary Crawford, RN
Activity 2 2 2 2
ATP-B-S:02:1001261385: Mary Crawford, RN
Able to deep breathe and cough freely (2)
Dyspnea or limited breathing (1)
Preop Visit:
Apneic (0) 2 2 2 2
Respiration
BP  20% of preanesthetic level
BP + 20% of preanesthetic level
BP + 50% of preanesthetic level Circulation 2 2 2 2
140/70
Fully awake (2)
Arouseable on calling (1)
Consciousness Postop Visit:
Not responding (0) 2 2 2 2
Pink (2) Color

Pale, dusky, blotchy, jaundiced, other (1) Cyanotic
(0) 2 2 2 2
Comments & Observations:

Oral pack removed c 1005 Ice applied to chin no active bleeding. 1030 patient states “feels like she’s
swallowing blood” - area clotted. Pressure pack applied to determined ooze. 1040 pack removed.
Small stain. No active bleeding noted ice removed at discharge.
Reviewed and Approved: Mary Crawford, RN
ATP-B-S:02:1001261385:Mary Crawford,
RN (Signed: 4/19/YYYY 10:56:00 AM EST)
Signature of Recovery Room Nurse
IPCase003 DOB: 02/08/YYYY MEDICATION ADMINISTRATION RECORD

Dr. DUNN ROOM: 244
SPECIAL INSTRUCTIONS: Allergic to Sulfa and Demerol

DATE: 04-18 DATE: 04-19 DATE: 04-20 DATE:
MEDICATION (dose and route)

TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALS
Lanoxin 0.125mg by mouth 0800 JD 0800 JD

daily
Lasix 40mg by mouth daily 0800 JD 0800 JD
Single Orders & Pre-Ops

Dalmane 30 mg by mouth at 2100 VT
bedtime
Vistaril 50 mg intramuscular Preop VT

1° pre op
Robinul 0.2 mg 1°pre op Preop VT
Nubain 10 mg intramuscular 1300 HF

now
Dalmane 30 mg at bedtime 2200 PS
PRN Medications:
Tylenol with codeine ½ grain 1140 JD
four times a day as needed
Tylenol #2 by mouth four 2040 PS 1245 HF

times a day as needed
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
RAY, PAM Admission: 04/18/YYYY EKG REPORT
Dr. DUNN ROOM: 244
Date of EKG: 04/18/YYYY Time of EKG 1345
Rate 70
PR .12
Sinus rhythm: Nonspecific ST wave changes since
QRSD .08 04/09/YYYY
QT .40
QTC
-- Axis --
P
QRS
T
Reviewed and Approved: Bella
Kaplan, MD
ATP-B-S:02:1001261385:
Bella Kaplan, MD
IPCase003 DOB: 02/08/YYYY NURSES' NOTES

Dr. DUNN ROOM: 244
DATE TIME TREATMENTS & MEDICATIONS TIME NURSES’ NOTES

04/18/YYYY 1345 A 62 year old white female admitted to room
244A for mouth surgery in morning. Allergic
to sulfa and Demerol.
Reviewed and Approved: V. South, RN ATP-B-

S:02:1001261385: V. South, RN
1430 Comfortable without complaint.
Reviewed and Approved: V. South, RN

ATP-B-S:02:1001261385: V. South, RN
04/18/YYYY 1600 Resting quietly. Asked to soak toe in tepid
water as was advised by Dr. Anderson who
treated her recently.
Reviewed and Approved: O. Richards, RN

ATP-B-S:02:1001261385: O. Richards, RN
1700 Ate only 30% of regular diet at bedside,
sore mouth cannot chew.

1830 Resting quietly, napping at times.

2000 Snack of ice cream, vital signs taken.

2040 Tylenol with codeine ½ 2100 Up as needed for self PM care, back rub
grain by mouth for pain given settled into bed

2200 Resting quietly not yet asleep

04/19/YYYY Thursday 2400 Awake without complaints. Nothing by mouth
for operating room in the morning.
Reviewed and Approved: Sandy OatesATP-B-

S:02:1001261385:,Sandy Oates RN
0300 Sleeping.


Dr. DUNN ROOM: 244

04/19/YYYY Thursday 0600 Awake, no complaints.

04/19/YYYY 0700 Thursday 0730 Awake – vital signs taken nothing by mouth
for surgery.
Reviewed and Approved: V. South, RN ATP-B-

S:02:1001261385: V. South, RN
(Signed: 04/19/YYYY 07:30:30 AM EST
0915 To Operating Room via stretcher. Reviewed
and Approved: V. South, RN

ATP-B-S:02:1001261385: V. South, RN
04/19/YYYY 1100 Returned from Operating Room fully awake.
Post operation vital signs started. Ice to
chin; sipping on Pepsi

ATP-B-S:02:1001261385: V. South, RN
1215 Up to bathroom with help—voided

ATP-B-S:02:1001261385: V. South, RN
1300 Nubain 10 milligrams 1230 Clear liquid lunch taken well.
intramuscular
ATP-B-S:02:1001261385: V. South, RN
1430 Resting in bed without complaints. Vital
signs finished.

ATP-B-S:02:1001261385: V. South, RN
04/19/YYYY 1530 Vital signs taken. Complains of difficulty
with speech and discomfort in front jaw.

1630 Sitting up, visitor here.

1730 85% of diet taken at supper.


Dr. DUNN ROOM: 244
04/19/YYYY 1830 Very little blood noted.

2000 Vital signs taken.

2100 Refused evening care.

04/19/YYYY 2200 States she is unable to see well due to
cataracts but refuses any night light.
Voiding.

04/20/YYYY Friday 2400 Sleeping soundly, skin warm and dry. No
apparent new bleeding from mouth. Ice
off at present.
Reviewed and Approved: Sandy Oates

ATP-B-S:02:1001261385:,Sandy Oates RN
0300 Awake. Wanting to gargle with salt water
and rinse out her mouth. No complaints.
Face slightly edematous and ecchymotic.

0600 Awake. Up to take bath; no complaints.

04/20/YYYY 0700- Friday 0730 Awake. Vital signs taken. No complaints.
1500
ATP-B-S:02:1001261385: V. South, RN
0830 Full liquid breakfast taken well.

ATP-B-S:02:1001261385: V. South, RN
04/20/YYYY 0930 Ice to face, resting in bed.

ATP-B-S:02:1001261385: V. South, RN

Dr. DUNN ROOM: 244

04/20/YYYY 1030 Rinsed mouth with warm salt water.

ATP-B-S:02:1001261385: V. South, RN
1100 Visitor in – no complaints.

ATP-B-S:02:1001261385: V. South, RN
Full liquid 1230 Lunch taken well.

ATP-B-S:02:1001261385: V. South, RN
1300 Complains still hungry—ordered up
applesauce & pudding for her to eat.

ATP-B-S:02:1001261385: V. South, RN
1430 Resting without complaints.

ATP-B-S:02:1001261385: V. South, RN
1515 Discharged.

ATP-B-S:02:1001261385: V. South, RN
RAY, PAM Admission: 04/18/YYYY NURSING DISCHARGE
STATUS SUMMARY
Dr. DUNN ROOM: 244
1. AFEBRILE: X Yes No
2. WOUND: X Clean/Dry Reddened Infected NA
3. PAIN FREE: X Yes No If “No,” describe:
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: As instructed by Dr. Dunn
8. INSTRUCTIONS GIVEN TO PATIENT/FAMILY: As ordered by Dr. Dunn
9. PATIENT/FAMILY verbalize understanding of instructions: X Yes No
10. DISCHARGED 1510 Via: Wheelchair Stretcher Ambulance Co.

at
X Ambulatory
Accompanied by: Vera South, RN to Front desk
COMMENTS:
DATE: 04/20/YYYY

ATP-B-S:02:1001261385: V. South, RN
SIGNATURE: (Signed: 04/20/YYYY 15:15:15 AM EST
RAY, PAM Admission: 04/18/YYYY PATIENT PROPERTY RECORD IPCase003 DOB:
02/08/YYYY
Dr. DUNN ROOM: 244
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: Pam Ray 04/18/YYYY
ATP-B-S:02:1001261385: Pam Ray
Reviewed and Approved: Andrea Witteman 04/18/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.
ATP-B-S:02:1001261385: Pam Ray 04/18/YYYY (Signed: 04/18/YYYY
10:28:44 AM EST
Reviewed and Approved: Andrea Witteman 04/18/YYYY

I have deposited valuables in the facility safe. The envelope number is .
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.
Note: Permission to reuse granted by Alfred State College and Michelle A. Green

HIM 200 Health Record

Uploaded by

Copyright:

Available Formats

HIM 200 Health Record

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

HIM 200 Health Record

Uploaded by

Copyright:

Available Formats

Note: Permission to reuse granted by Alfred State College and Michelle A.

100 Main St, Alfred NY 14802 INPATIENT FACE SHEET

ALMOND, NY 14804 02/08/YYYY 63 NA Cleaner

RAY, PAM RAY, MATT

Diseased and carious mandibular teeth.

Extraction of 6 mandibular teeth. Mandibular alveolectomy.

Signature of Parent/Legal Guardian for Minor

WITNESS: Global Care Medical Center Staff Member

CONSENT TO RELEASE INFORMATION FOR REIMBURSEMENT PURPOSES

Signature of Parent/Legal Guardian for Minor

JONES, SARA Admission: 04/18/YYYY

HOSPITAL STAFF DIRECTIONS: Check when each step is completed.

Name of Individual Receiving Information Relationship to Patient

Name of Patient Name of Individual giving information if different from Patient

ADMISSION DATE: 04/18/YYYY

DISCHARGE DATE: 04/20/YYYY ADMISSION DIAGNOSIS: Diseased

and carious mandibular teeth.

OPERATION: Extraction of 6 mandibular teeth, mandibular

REVIEW OF SYSTEMS: Cardiorespiratory system: No chest pain, no cough or cold, no ankle

EXTERNAL GENITALIA: Normal.

DD: 04/18/YYYY Reviewed and Approved: Harold Dunn MD

DD: 04/20/YYYY Reviewed and Approved: S. Anderson DPM

04/18/YYYY 1352 CHIEF COMPLAINT: Jaw pain. DIAGNOSIS: Diseased teeth

04/18/YYYY 2100 Pre-Op Care: 2125

Reviewed and Approved: Jon Black DDS ATP-B-

04/19/YYYY 1000 General anesthesia. 6 extractions and alveolectomy. To

Reviewed and Approved: Jon Black DDS ATP-B-

04/19/YYYY 1200 Recovery uneventful. Appointment given for 04/24

Reviewed and Approved: Jon Black DDS ATP-B-

04/19/YYYY Podiatry: recovering from infected ingrown toenail

04/18/YYYY 1000 1) Admit service Dr. Dunn, Black

4) complete blood count, urinalysis, Protime, PTT

Reviewed and Approved: Jon Black DDS ATP-B-

1200 History and physical dictated. OK general anesthesia.

Reviewed and Approved: Harold Dunn MD

Lasix 40 milligrams by mouth daily. Codeine with Tylenol

Reviewed and Approved: Harold Dunn MD ATP-B-

04/19/YYYY 0700 Call Dr. Anderson to see patient today.

Reviewed and Approved: Jon Black DDS ATP-B-

1000 1) Ice to chin

Reviewed and Approved: Jon Black DDS ATP-B-

04/19/YYYY 1100 Resume:

Reviewed and Approved: Harold Dunn MD ATP-B-

04/19/YYYY 1200 Discharge tomorrow at discretion of Dr. Dunn

Reviewed and Approved: Jon Black DDS ATP-B-

04/19/YYYY 1230 Nubain 10 milligram intramuscular now

Reviewed and Approved: Harold Dunn MD ATP-B-

04/19/YYYY 1800 Dalmane 30 milligrams by mouth at bedtime

Reviewed and Approved: Harold Dunn MD ATP-B-

04/20/YYYY 0700 Discharge

Reviewed and Approved: Harold Dunn MD ATP-B-

SPECIMEN COLLECTED: 04/18/YYYY 1315 SPECIMEN RECEIVED: 04/18/YYYY 1402

BLEEDING TIME NORMAL 1-4 MINUTES Pt: SEC.

X PROTIME CONTROL: 12.5 SEC. Pt: 12.8 SEC.

X PTT NORMAL: <32 SEC. Pt: 22 SEC.

FIBRINDEX CONTROL: Pt:

FIBRINOGEN NORMAL: Pt: F.D.P. NORMAL: Pt:

CLOT RETRACTION NORMAL 30-65% Pt: %

CLOT LYSIS 24hr: 48 hr: