Organization Clinical Tool
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This document contains a patient's medical information including their name, date of birth, physician, code status, allergies, diet, medications, vital signs, lab results, procedures, consultations and notes from their hospital stay. Key details recorded include intravenous fluids and outputs, neurological and physical exam findings, cardiac and respiratory status, pain assessments, wound care and mobility level. The prior nursing shift report and any new orders or consultations are also documented.
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0130: Admission nurses note (RN): Client arrived via EMS from long-term-care for evaluation of low blood sugar. Pt. arrived confused (alert and oriented X 1) and is a known diabetic. Finger stick was 45. Orange juice and crackers, given repeat finger stick 104. Pt now alert and oriented X 4. Report from the charge nurse at the long-term-care facility indicates that the client has been having frequent bouts of hypoglycemia.
0530: (RN) Foley catheter inserted for incontinence--pt. too weak to get up to the bathroom and is experiencing bouts of incontinence.
600 mL clear yellow urine noted. The nurse indicates that the ER is very busy and short-staffed. 0545 (Admitting Physician) See history and physical. Pt. admitted to the medical-surgical service for evaluation of recurrent hypoglycemia.
View the ER chart before the pt. is transferred to the floor:
0730: (RN) Report is given to RN on 3 North.
Emergency Department Chart
Client: Mabel Simpson
DOB: 4/23/1941
Admission Date 8/16/2019
Medical Diagnosis: recurrent hypoglycemia
Allergies: None
Vitals/ Data Collection:
Temp.- 97.3 PO
History:
Diabetes (insulin dependent)油油
Medications:
Insulin R titrated to finger sticks
Allergies:
None
Vitals/ Data Collection:
Pulse- 68
History:
Hypertension
Medications:
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Allergies:
None
Vitals/ Data Collection:
Respirations- 18
History:
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Medications:
Warfarin 5 Mg Mon, Wed, Fri 2 Mg Tues, Thurs
Allergies:
None
Vitals/ Data Collection:
Blood Pressure- 122/86
History:
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Medications:
Enalapril 5 Mg once per day
Allergies:
None
Vitals/ Data Collection:
No C/O pain
History:
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Medications:
Proventil inhaler as needed for wheezing
Allergies:
None
Vitals/ Data Collection:
Alert and oriented X 4
History:
Former Smoker- smoked 1 pack per day X 40 years- last smoked 10 years ago
Medications:
Methotrexate 2.5 Mg per day
Allergies:
None
Vitals/ Data Collection:
Lungs: No adventitious sounds
History:
Appendectomy as a child
Medications:
Tylenol 650 Mg as needed for pain or fever
Allergies:
None
Vitals/ Data Collection:
+ Bowel sounds
History:
Mobility (baseline): able to ambulate slowly with minimal assist
Clear yellow urine draining from Foley catheter in adequate amts.
Medications:油
Allergies:
None
Vitals/ Data Collection:
Clear yellow urine draining from Foley catheter in adequate amts.
History:油
Medications:油
Allergies:
None
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10:00: (RN) Pt received on 3 North. Alert and oriented X 4. Fingerstick 81. Eating breakfast. Offering no complaints.
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Mr. Jones is a 77-year-old man hospitalized for right middle lobe pneumonia who spiked a fever. His chest x-ray and vital signs have improved with IV antibiotics. The doctor plans to monitor for possible sepsis given the fever and redness at his IV site, starting normal saline and being prepared to involve the ICU if needed overnight. Any questions from the night team should be directed to checking his vital signs and exam.Admission Form - Pain
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0130: Admission nurses note (RN): Client arrived via EMS from long-term-care for evaluation of low blood sugar. Pt. arrived confused (alert and oriented X 1) and is a known diabetic. Finger stick was 45. Orange juice and crackers, given repeat finger stick 104. Pt now alert and oriented X 4. Report from the charge nurse at the long-term-care facility indicates that the client has been having frequent bouts of hypoglycemia.
0530: (RN) Foley catheter inserted for incontinence--pt. too weak to get up to the bathroom and is experiencing bouts of incontinence.
600 mL clear yellow urine noted. The nurse indicates that the ER is very busy and short-staffed. 0545 (Admitting Physician) See history and physical. Pt. admitted to the medical-surgical service for evaluation of recurrent hypoglycemia.
View the ER chart before the pt. is transferred to the floor:
0730: (RN) Report is given to RN on 3 North.
Emergency Department Chart
Client: Mabel Simpson
DOB: 4/23/1941
Admission Date 8/16/2019
Medical Diagnosis: recurrent hypoglycemia
Allergies: None
Vitals/ Data Collection:
Temp.- 97.3 PO
History:
Diabetes (insulin dependent)油油
Medications:
Insulin R titrated to finger sticks
Allergies:
None
Vitals/ Data Collection:
Pulse- 68
History:
Hypertension
Medications:
Furosemide 20 MG twice per day
Allergies:
None
Vitals/ Data Collection:
Respirations- 18
History:
Atrial Fibrillation
Medications:
Warfarin 5 Mg Mon, Wed, Fri 2 Mg Tues, Thurs
Allergies:
None
Vitals/ Data Collection:
Blood Pressure- 122/86
History:
Rheumatoid Arthritis油油油
Medications:
Enalapril 5 Mg once per day
Allergies:
None
Vitals/ Data Collection:
No C/O pain
History:
Mild Heart Failure (class 1)
Medications:
Proventil inhaler as needed for wheezing
Allergies:
None
Vitals/ Data Collection:
Alert and oriented X 4
History:
Former Smoker- smoked 1 pack per day X 40 years- last smoked 10 years ago
Medications:
Methotrexate 2.5 Mg per day
Allergies:
None
Vitals/ Data Collection:
Lungs: No adventitious sounds
History:
Appendectomy as a child
Medications:
Tylenol 650 Mg as needed for pain or fever
Allergies:
None
Vitals/ Data Collection:
+ Bowel sounds
History:
Mobility (baseline): able to ambulate slowly with minimal assist
Clear yellow urine draining from Foley catheter in adequate amts.
Medications:油
Allergies:
None
Vitals/ Data Collection:
Clear yellow urine draining from Foley catheter in adequate amts.
History:油
Medications:油
Allergies:
None
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10:00: (RN) Pt received on 3 North. Alert and oriented X 4. Fingerstick 81. Eating breakfast. Offering no complaints.
8/17/2019 (Medical Assistant)
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The document defines focus charting as a systematic method for organizing health information using nursing terminology to describe a patient's health status and care. It involves focusing on key concerns from the care plan like skin integrity or symptoms like nausea. A focus note includes subjective and objective data supporting the focus, nursing interventions, and the patient's response. An example focus note addresses a patient's pain by documenting their complaint, administering medication, repositioning the patient, and noting their improved pain level in response.F-Dar, Focus Charting
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油
The document defines focus charting as a systematic method for organizing health information using nursing terminology to describe a patient's health status and care. It involves focusing on key concerns from the care plan like skin integrity or activity tolerance. A focus note includes subjective and objective data supporting the focus, nursing interventions, and the patient's response. An example focus note addresses a patient's pain by documenting their complaint, administering medication, repositioning the patient, and noting their improved pain level in response.Cardiology ICD-10 records with Dual Coding-ICD-10 Training
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This document contains a summary of a patient's medical history and appointment for issues related to cardiovascular health. Specifically:
- The patient is a 68-year-old man with a history of ischemic cardiac disease, hypercholesterolemia, and facial tics who is following up on his conditions.
- He had a myocardial infarction in 1996 and underwent bypass surgery. His cardiac condition has been stable without symptoms.
- He is taking medications to control his cholesterol and cardiac conditions.
- Examination found him in stable condition, and he will continue his current treatment plan and follow up with his doctors.Patient assessment
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油
Mary Corcoran provides an overview of patient assessment for emergency room nurses. ER nurses must be prepared to assess patients with a wide range of medical, surgical, traumatic, social and behavioral complaints spanning all ages. The initial assessment involves a primary survey of the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) followed by a secondary survey of FGHI (Full set of vitals, pain assessment, history, head-to-toe exam, inspection of posterior surfaces). Special populations like children, elderly, obese, and pregnant women require modification of the standard assessment process. Ongoing reassessment is important for patients with changing conditions or receiving certain treatments.Procedures IM.docx
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油
No acute issues identified on exam today. Continue current medications and follow up as scheduled. Let me know if any new concerns arise.Clinical Template .pdf
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油
This document contains templates for head-to-toe patient assessments, documentation of vital signs and labs, care plans, and SBAR communication. The head-to-toe assessment template guides the nurse through inspecting, palpating, percussing, and auscultating each body system. The care plan template includes sections for past medical history, current plan of care, comorbidities, discharge needs, and orders. The SBAR template provides a structure for communicating a patient's situation, background, assessment findings, and recommended actions to the attending physician.螳危旧/蠍 ル襷レ蟲 豌覦
螳危旧/蠍 ル襷レ蟲 豌覦a7309dcb
油
This document contains admission orders for a patient presenting with chest pain or acute coronary syndrome. The orders cover diagnostics, medications, monitoring, diet, activity, vaccinations and protocols to guide inpatient management and prepare for discharge. The goal is to diagnose the cause of chest pain, initiate guideline recommended treatments, provide education and refer for outpatient rehabilitation.Overview and Preparation for the 2020 Clinical Simulation Exam (CSE) Portion ...
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Organization Clinical Tool
- 1. Patient DOB Sex Date Adm. Date Physician Code Status Isolation Allergies Diet NPO Fluid Restriction Marital Status Next of kin Religion Admitting Diagnosis Past Medical History Past Surgical History Meds: 08 10 12 14 Charting: 09 11 13 15 PT/OT/ST/: 08 10 12 14 IV#: TYPE: Location: IV Rate: 0700: Solution _________ Condition _____________ 0900: Solution _________ Condition _____________ 1100: Solution _________ Condition _____________ 1300: Solution _________ Condition _____________ 1500: Solution _________ Condition _____________ Vitals: 0800: T___ P ___ R ___ BP ___ Sats ____ Pain _____ 1000: T___ P ___ R ___ BP ___ Sats ____ Pain _____ 1200: T___ P ___ R ___ BP ___ Sats ____ Pain _____ 1400: T___ P ___ R ___ BP ___ Sats ____ Pain _____ Accu-cheks: 0800______ 1200_______ 1600_____ 2000______ NEURO LOC _____________ Orientation_________ Mental status_______ PERRLA__________ Paralysis___________ Paresthesia_________ CARDIAC A/Pulse_______ P. Pulses______ Edema________ Cap refill______ Chest pain_____ TEDS________ RESPIRATORY RA______________ O2 ______________ Lungs ___________ SOB_____________ Cough ___________ Trachea__________ ELIMINATION B/Room _________ B/Pan ___________ Urinal ___________ Incontinent_______ Foley ___________ Urine____________ Stools___________ ACTIVITY B/Rest___________ Ambulates________ Gait_____________ Walker __________ Cane ____________ Assistance________ INTEGUMENTARY Color_____________ Warm/dry__________ Rashes____________ Turgor____________ Pressure areas______ GI Bowel sounds__ Abdomen______ Appetite_______ Nausea________ Vomit________ Dentures______ WOUND Incisions_________ Dressings_________ Drains___________ Staples___________ Chest tubes_______ PAIN EVAL Onset____________ Provocation_______ Quality__________ Region__________ Severity__________ Time____________ SPECIAL Telemetry________ Ventilator________ Enteral feed______ NG tube_________ Colostomy_______ Ileostomy________ TIME IN OUT TOTAL LAB VALUE K Na H&H WBC BUN CR Trop Mg pH Lactate HCO3 PCO2 PREVIOUS SHIFT REPORT: CONSULTS/ORDERS: CXR / CT / MRI / US / heart cath. / surgery? NOTES: Precautions: contact / fall / seizure / aspiration / neuro