Note: Permission to reuse granted by Alfred State College and Michelle A. Green
 | Global Care Medical Center 100 Main St, Alfred NY 14802(607) 555-1234Hospital No. 999inpatient Face Sheet | ||||||||
| Patient Name and Address | Gender | Race | Marital Status | Patient No. | |||||
| RAY, PAM380 HOWE ROAD ALMOND, NY 14804 | F | W | S | IPCase003 | |||||
| Date of Birth | Age | Maiden Name | Occupation | ||||||
| 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, PAM380 HOWE ROAD ALMOND, NY 14804 | RAY, MATT380 HOWE ROAD 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 upin office in one week | |||||||||
| Special Instructions: None | |||||||||
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| CONSENT TO ADMISSIONRAY, PAM Admission: 04/18/YYYY IPCase003 DOB: 02/08/YYYYDr. DUNN ROOM: 244 |
| I, Pam Ray hereby consent to admission to the Global Care Medical Center (ASMC) , and I further consent to suchroutine 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 PatientSignature of Parent/Legal Guardian for Minor Relationship to MinorReviewed 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 rende red 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 MinorWITNESS: Global Care Medical Center Staff Member |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 |
| JONES, SARA Admission: 04/18/YYYYAdvance DirectiveIPCase003 DOB: 02/08/YYYYDr. 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 Initials1. 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 XHospital with a copy for your medical record. |
| 3. Have you prepared a Durable Power of Attorney for Health Care? XIf yes, please provide the Hospital with a copy for your medical record. |
| 4. Have you provided this facility with an Advance Directive on a Xprior 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 XAttorney? If yes, refer to in order: a.Physicianb. Social Servicec. Volunteer Service |
| HOSPITAL STAFF DIRECTIONS: Check when each step is completed. |
| __Verify the above questions where answered and actions taken where required.✓ If the “Patient Rights” information was provided to someone other than the patient, state reason: Name of Individual Receiving Information Relationship to Patient✓ If information was provided in a language other than English, specify language and method.✓ Verify patient was advised on how to obtain additional information on Advance Directives.✓ 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 PatientReviewed and Approved: Pam Ray ATP-B-S:02:1001261385: Pam Ray(Signed: 4/18/YYYY 2:35:05 PM EST)Signature of Patient DateReviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 4/18/YYYY 2:35:47 PM ESTSignature of Hospital Representative Date |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 |
| RAY, PAM Admission: 04/18/YYYYDischarge SummaryIPCase003 DOB: 02/08/YYYYDr. DUNN ROOM: 244 |
ADMISSION DATE: 04/18/YYYYDISCHARGE 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/YYYYDT: 04/21/YYYY Physician Name |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 |
| RAY, PAMIPCase003 Dr. DUNN | Admission: 04/18/YYYY DOB:ROOM: 244 | History & Physical Exam | |
| 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(Signed: 4/20/YYYY 2:20:44 PM EST) | ||
| DT: 04/19/YYYY | Physician Name | ||
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 | |||
| RAY, PAM Admission: 04/18/YYYYConsultation ReportIPCase003 DOB: 02/08/YYYYDr. DUNN ROOM: 244 |
S. Anderson, DPMDr. 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 DPMATP-B-S:02:1001261385: S. Anderson DPM (Signed: 4/20/YYYY 2:20:44 PM EST)DT: 04/23/YYYY Physician Name |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 |
| RAY, PAM Admission: 04/18/YYYYProgress NotesIPCase003 DOB: 02/08/YYYYDr. 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: 212563 year old female Plan general anesthesia Physical exam pending. Reviewed and Approved: Jon Black DDS ATP-B-S:02:1001261385: Jon Black DDS(Signed: 4/18/YYYY 21:20:44 PM EST) |
| 04/19/YYYY | 1000 | General anesthesia. 6 extractions and alveolectomy. To Recovery Room in good condition. Reviewed and Approved: Jon Black DDS ATP-B-S:02:1001261385: Jon Black DDS(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. Reviewed and Approved: Jon Black DDS ATP-B-S:02:1001261385: Jon Black DDS(Signed: 4/19/YYYY 12:03:30 PM EST) |
| 04/19/YYYY | Podiatry: recovering from infected ingrown toenail right – 1 medial border. Healing very well. Advisedto contact me as needed. Thank you! | |
| GLOBAL MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 | ||
| RAY, PAM Admission: 04/18/YYYYDoctors’ OrdersIPCase003 DOB: 02/08/YYYYDr. 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 | ||
| Vistaril 50 milligrams intramuscular 1° pre op | ||
| Reviewed and Approved: Jon Black DDS ATP-B- | ||
| S:02:1001261385: Jon Black DDS | ||
| (Signed: 4/18/YYYY 10:09:30 AM EST) | ||
| 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(Signed: 4/18/YYYY 12:11:17 PM EST) | |
| 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(Signed: 4/18/YYYY 12:16:27 PM EST) | ||
| 04/19/YYYY | 0700 | Call Dr. Anderson to see patient today. Reviewed and Approved: Jon Black DDS ATP-B-S:02:1001261385: Jon Black DDS(Signed: 4/18/YYYY 10:09:30 AM EST) |
| 1000 | Ice to chinRemove oral pack in Recovery RoomLiquid dietDr. Dunn for medical ordersTylenol #2 by mouth every 4 hours as neededDischarged from Recovery Room at 1055 Reviewed and Approved: Jon Black DDS ATP-B-S:02:1001261385: Jon Black DDS(Signed: 4/19/YYYY 10:09:30 AM EST) | |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 | ||
| RAY, PAM Admission: 04/18/YYYYDoctors’ OrdersIPCase003 DOB: 02/08/YYYYDr. 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 Reviewed and Approved: Harold Dunn MD ATP-B-S:02:1001261385: Harold Dunn MD (Signed: 4/19/YYYY 11:16:27 AM EST) |
| 04/19/YYYY | 1200 | Discharge tomorrow at discretion of Dr. Dunn To report to my office 04/24 Reviewed and Approved: Jon Black DDS ATP-B-S:02:1001261385: Jon Black DDS(Signed: 4/19/YYYY 12:03:45 PM EST) |
| 04/19/YYYY | 1230 | Nubain 10 milligram intramuscular now Reviewed and Approved: Harold Dunn MD ATP-B-S:02:1001261385: Harold Dunn MD(Signed: 4/19/YYYY 12:33:52 PM EST) |
| 04/19/YYYY | 1800 | Dalmane 30 milligrams by mouth at bedtime Reviewed and Approved: Harold Dunn MD ATP-B-S:02:1001261385: Harold Dunn MD(Signed: 4/19/YYYY 18:04:26 PM EST) |
| 04/20/YYYY | 0700 | Discharge Reviewed and Approved: Harold Dunn MD ATP-B-S:02:1001261385: Harold Dunn MD (Signed: 4/20/YYYY 07:06:00 AM EST) |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 | ||
| RAY, PAM Admission: 04/18/YYYYLaboratory DataIPCase003 DOB: 02/08/YYYYDr. DUNN ROOM: 244 |
| Specimen Collected: 04/18/YYYY 1315 Specimen Received: 04/18/YYYY 1402 |
| HEMATOLOGY II3PLATELET 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*** |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 |
| RAY, PAMIPCase003 Dr. DUNN | Admission: 04/18/YYYY DOB: 02/08/YYYYROOM: 244 | Laboratory Data |
| TIME IN: 04/18/YYYY 1315 TIME OUT: 04/14/YYYY 1503 |
| CBC S DIFFERENTIAL ***End of Report*** |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 |
| RAY, PAM Admission: 04/18/YYYYLaboratory DataIPCase003 DOB: 02/08/YYYYDr. DUNN ROOM: 244 |
| Specimen Collected: 04/18/YYYY 1315 Specimen Received: 04/18/YYYY 1341 |
URINALYSIS TestResultFlagReferenceWBC6.8 4.5-11.0thous/UL RBC4.22 5.2-5.4mill/UL HGB13.5 11.7-16.1g/dl HCT39.6 35.0-47.0% MCV93.9 85-99fL. MCH32.1 MCHC34.2 33-37 RDW11.4-14.5 PTL135 130-400thous/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 1031.2-3.4 MONO x 1030.11-0.59 GRAN x 1031.4-6.5 EOS x 1030.0-0.7 BASO x 1030.0-0.2 ANISO TestResultFlagReference DIPSTICK ONLY COLORStraw Ph.6.5 5-8.0 SP. GR.1.011 1.030 ALBUMINNeg SUGARNeg 10 mg/dl ACETONENeg BILIRUBINNeg 0.8 mg/dl BLOODNeg 0.06 mg/dl hgb REDUCING -1 mg/dl EPITH:2+ W.B.C.:Occasional5/hpf R.B.C.:- 5/hpf BACT.:Few 1+( 20/hpf) CASTS.:- CRYSTALS:- ***End of Report*** |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 |
| RAY, PAM Admission: 04/18/YYYY CONSENT FOR OPERATION(S) ANDIORIPCase003 DOB: 02/08/YYYY Procedure(s) and AnesthesiaDr. 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 Raythe 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. Dunnhas 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.Reviewed and Approved: Pam RayPatient/Relative/Guardian* ATP-B-S:02:1001261385: Pam Ray Pam Ray(Signed: 04/18/YYYY 2:12:05 PM EST)Signature Print NameRelationship, if other than patient signed:Reviewed and Approved: William PrestonWitness:ATP-B-S:02:1001261385: William Preston William Preston(Signed: 04/18/YYYY 2:13:00 PM ESTSignature 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 MDPHYSICIAN: ATP-B-S:02:1001261385: Harold Dunn MD §[‡(؇{{{{(Signed: 4/18/YYYY 2:20:44 PM EST)Signature Date |
| GLOBAL MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 |
| RAY, PAM Admission: 04/18/YYYYOperative ReportIPCase003 DOB: 02/08/YYYYDr. 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/YYYYANESTHESIA: 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 (Signed: 4/20/YYYY 2:20:44 PM EST)DT: 04/23/YYYY Physician Name |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 |
| RAY, PAM Admission: 04/18/YYYYPathology ReportIPCase003 DOB: 02/08/YYYYDr. DUNN ROOM: 244 | ||||||||||||||||||||||||||||||
Date of Surgery: 04/19/YYYY OPERATION: Extraction of teeth. SPECIMEN: teethGROSS: 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 (Signed: 4/20/YYYY 2:20:44 PM EST) DT:4/20/YYYY | ||||||||||||||||||||||||||||||
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 | ||||||||||||||||||||||||||||||
| RAY, PAM | Admission: 04/18/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 Tim | |||||||||||||||||||||
| 230 | Operation: extraction | |||||||||||||||||||||||||||||
| 220 | Anesthesia: | General | ||||||||||||||||||||||||||||||
| 210 |  |  |  |  |  |  | o | Airway: | N/A | |||||||||||||||||||||||
| 200 | O2 Used: Route: | □Yes © No | ||||||||||||||||||||||||||||||
| 190 | |  |  |  |  | | | |||||||||||||||||||||||||
| 180 | Time | Medication s | Site | |||||||||||||||||||||||||||||
| 170 |  |  |  |  |  |  |  | |||||||||||||||||||||||||
| 160 | ||||||||||||||||||||||||||||||||
| 150 | ||||||||||||||||||||||||||||||||
| 140 | Y | Y | Y | Y | Y | Y | ||||||||||||||||||||||||||
| 130 | Y | Y | Y | Y | Intake | Amoun t | ||||||||||||||||||||||||||
| 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: | |||||||||||||||||||||||||||||||
| hermoscan | probe. Oral mode | q9 | adm. | Condition: Satisfactory | ||||||||||||||||||||||||||||
| PostAnesthesia Recovery Score | Ad m | 30 min | 1hr | 2hr | Disc h | Transferred by Stretcher | ||||||||||||||||||||||||||
| Moves 4 extremities voluntarily or on command (2) Moves 2 extremities voluntarily or on command (1)Moves 0 extremities voluntarily or on command (0) | Activity | 2 | 2 | 2 | 2 | R.R. Nurse:Rev& App: Mary Crawford, RNATP-B-S:02:1001261385:Mary Crawford, RN (Signed: 4/19/YYYY10:56:00 AM EST) | ||||||||||||||||||||||||||
| Able to deep breathe and cough freely (2) Dyspnea or limited breathing (1)Apneic (0) | Respiration | 2 | 2 | 2 | 2 | Preop Visit: | ||||||||||||||||||||||||||
| BP 20% of preanesthetic levelBP + 20% of preanesthetic level BP + 50% of preanesthetic level | Circulation140/70 | 2 | 2 | 2 | 2 | |||||||||||||||||||||||||||
| Fully awake (2) Arouseable on calling (1) Not responding (0) | Consciousnes s | 2 | 2 | 2 | 2 | Postop Visit: | ||||||||||||||||||||||||||
| Pink (2)Pale, dusky, blotchy, jaundiced, other (1) Cyanotic (0) | Color | 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 |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 |
| RAY, PAM Admission: 04/18/YYYYIPCase003 DOB: 02/08/YYYY MEDICATION ADMINISTRATION RECORDDr. 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 | 0800 | JD | 0800 | JD | |||||||
| daily | |||||||||||
| Single Orders & Pre-Ops | |||||||||||
| Dalmane 30 mg by mouth | 2100 | VT | |||||||||
| at | |||||||||||
| bedtime | |||||||||||
| Vistaril 50 mg | Preop | VT | |||||||||
| intramuscular | |||||||||||
| 1° pre op | |||||||||||
| Robinul 0.2 mg 1°pre op | Preop | VT | |||||||||
| Nubain 10 mgintramuscular | 1300 | HF | |||||||||
| now | |||||||||||
| Dalmane 30 mg at bedtime | 2200 | PS | |||||||||
| PRN Medications: | |||||||||||
| Tylenol with codeine ½grain | 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 | |||||||||||||||||
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 | ||||||||||||||||||
| RAY, PAM Admission: 04/18/YYYY EKG REPORTIPCase003 DOB: 02/08/YYYYDr. DUNN ROOM: 244 |
| Date of EKG: 04/18/YYYY Time of EKG 1345Rate 70PR .12Sinus rhythm: Nonspecific ST wave changes sinceQRSD .08 04/09/YYYYQT .40QTC– Axis –P QRSTReviewed and Approved:Bella Kaplan, MD ATP-B-S:02:1001261385:Bella Kaplan, MD (Signed: 04/19/YYYY 8:54:14 PM EST)  |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 |
RAY, PAM Admission: 04/18/YYYY IPCase003 DOB: 02/08/YYYY NURSES’ NOTESDr. 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 (Signed: 04/18/YYYY 13:49:41 PM EST) | ||
| 1430 | Comfortable without complaint. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN(Signed: 04/18/YYYY 14:32:23 PM EST) | |||
| 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 (Signed: 04/18/YYYY 16:04:20 PM EST) | ||
| 1700 | Ate only 30% of regular diet at bedside, sore mouth cannot chew. Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN (Signed: 04/18/YYYY 17:04:00 PM EST) | |||
| 1830 | Resting quietly, napping at times. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN(Signed: 04/18/YYYY 18:32:06 PM EST) | |||
| 2000 | Snack of ice cream, vital signs taken. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 04/18/YYYY 20:04:04 PM EST) | |||
| 2040 | Tylenol with codeine ½ | 2100 | Up as needed for self PM care, back rub | |
| grain by mouth for pain | given settled into bedReviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 04/18/YYYY 21:07:220 PM EST) | |||
| 2200 | Resting quietly not yet asleep Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 04/18/YYYY 22:14:33 PM EST) | |||
| 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 (Signed: 04/19/YYYY 00:12:08 PM EST) | |
| 0300 | Sleeping. Reviewed and Approved: Sandy OatesATP-B-S:02:1001261385:,Sandy Oates RN (Signed: 04/19/YYYY 03:04:17 AM EST) | |||
| GLOBAL MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 | ||||
RAY, PAM Admission: 04/18/YYYY IPCase003 DOB: 02/08/YYYY NURSES’ NOTESDr. DUNN ROOM: 244 | ||||
| DATE | TIME | TREATMENTS & MEDICATIONS | TIME | NURSES’ NOTES |
| 04/19/YYYY | Thursday | 0600 | Awake, no complaints. Reviewed and Approved: Sandy OatesATP-B-S:02:1001261385:,Sandy Oates RN (Signed: 04/19/YYYY 06:07:45 AM EST) | |
| 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 Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 04/19/YYYY 09:15:18 AM EST | |||
| 04/19/YYYY | 1100 | Returned from Operating Room fully awake. Post operation vital signs started. Ice to chin; sipping on Pepsi Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN(Signed: 04/19/YYYY 11:09:24 AM EST | ||
| 1215 | Up to bathroom with help—voided Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 04/19/YYYY 12:15:41 PM EST | |||
| 1300 | Nubain 10 milligrams intramuscular | 1230 | Clear liquid lunch taken well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN(Signed: 04/19/YYYY 13:00:41 PM EST | |
| 1430 | Resting in bed without complaints. Vital signs finished. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 04/19/YYYY 13:49:41 PM EST | |||
| 04/19/YYYY | 1530 | Vital signs taken. Complains of difficulty with speech and discomfort in front jaw. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN(Signed: 04/19/YYYY 15:34:30 PM EST) | ||
| 1630 | Sitting up, visitor here. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 04/19/YYYY 16:35:43 PM EST | |||
| 1730 | 85% of diet taken at supper. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 04/19/YYYY 17:32:11 PM EST | |||
| GLOBAL MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 | ||||
RAY, PAM Admission: 04/18/YYYY IPCase003 DOB: 02/08/YYYY NURSES’ NOTESDr. DUNN ROOM: 244 | ||||
| DATE | TIME | TREATMENTS & MEDICATIONS | TIME | NURSES’ NOTES |
| 04/19/YYYY | 1830 | Very little blood noted. Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 04/19/YYYY 18:31:22 PM EST | ||
| 2000 | Vital signs taken. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O.Richards, RN(Signed: 04/19/YYYY 20:07:27 PM EST | |||
| 2100 | Refused evening care. Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 04/19/YYYY 21:06:28 PM EST | |||
| 04/19/YYYY | 2200 | States she is unable to see well due to cataracts but refuses any night light. Voiding. Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 04/19/YYYY 22:02:35 PM EST | ||
| 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 OatesATP-B-S:02:1001261385:,Sandy Oates RN (Signed: 04/19/YYYY 00:12:17 PM EST) | |
| 0300 | Awake. Wanting to gargle with salt water and rinse out her mouth. No complaints. Face slightly edematous and ecchymotic. Reviewed and Approved: Sandy Oates ATP-B-S:02:1001261385:,Sandy Oates RN (Signed: 04/19/YYYY 03:12:22 AM EST) | |||
| 0600 | Awake. Up to take bath; no complaints.Reviewed and Approved: Sandy Oates ATP-B-S:02:1001261385:,Sandy Oates RN (Signed: 04/20/YYYY 06:02:44 AM EST) | |||
| 04/20/YYYY | 0700- | Friday | 0730 | Awake. Vital signs taken. No complaints. |
| 1500 | Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 04/20/YYYY 07:32:32 AM EST | |||
| 0830 | Full liquid breakfast taken well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 04/20/YYYY 08:34:08 AM EST | |||
| 04/20/YYYY | 0930 | Ice to face, resting in bed.Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 04/20/YYYY 09:32:10 AM EST | ||
| GLOBAL MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 | ||||
RAY, PAM Admission: 04/18/YYYY IPCase003 DOB: 02/08/YYYY NURSES’ NOTESDr. DUNN ROOM: 244 | ||||
| DATE | TIME | TREATMENTS & MEDICATIONS | TIME | NURSES’ NOTES |
| 04/20/YYYY | 1030 | Rinsed mouth with warm salt water. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 04/20/YYYY 10:31:18 AM EST | ||
| 1100 | Visitor in – no complaints.Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 04/20/YYYY 11:01:09 AM EST | |||
| Full liquid | 1230 | Lunch taken well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 04/20/YYYY 12:32:32 AM EST | ||
| 1300 | Complains still hungry—ordered up applesauce & pudding for her to eat. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN(Signed: 04/20/YYYY 13:14:28 AM EST | |||
| 1430 | Resting without complaints. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 04/20/YYYY 14:36:15 AM EST | |||
| 1515 | Discharged. Reviewed and Approved: V. South, RNATP-B-S:02:1001261385: V. South, RN (Signed: 04/20/YYYY 15:15:15 AM EST | |||
| GLOBAL MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 | ||||
| RAY, PAM Admission: 04/18/YYYY NURSING DISCHARGEIPCase003 DOB: 02/08/YYYYStatus SummaryDr. 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. | DISCHARGEDat | 1510 | Via: | Wheelchair | Stretcher | Ambulance Co. | ||||||||||||||||
X | Ambulatory | |||||||||||||||||||||
Accompanied by: | Vera South, RN | to | Front desk | |||||||||||||||||||
COMMENTS: | ||||||||||||||||||||||
DATE: | 04/20/YYYY | |||||||||||||||||||||
SIGNATURE: | Reviewed and Approved: V. South, RNATP-B-S:02:1001261385: V. South, RN (Signed: 04/20/YYYY 15:15:15 AM EST | |||||||||||||||||||||
| GLOBAL MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 | ||||||||||||||||||||||
| RAY, PAM Admission: 04/18/YYYY PATIENT PROPERTY RECORDIPCase003 DOB: 02/08/YYYYDr. 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(Signed: 04/18/YYYY 10:26:44 AM ESTSignature of Patient DateReviewed and Approved: Andrea Witteman 04/18/YYYY ATP-B-S:02:1001261385: Andrea Witteman(Signed: 09/24/YYYY 10:27:44 AM ESTSignature 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: Pam RayATP-B-S:02:1001261385: Pam Ray 04/18/YYYY (Signed:04/18/YYYY 10:28:44 AM ESTSignature of Patient DateReviewed and Approved: Andrea Witteman 04/18/YYYY ATP-B-S:02:1001261385: Andrea Witteman(Signed: 09/24/YYYY 10:29:44 AM ESTSignature 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 administrationSignature of Patient Date Signature of Witness Date |
| GLOBAL CARE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ (607) 555-1234 |
Note: Permission to reuse granted by Alfred State College and Michelle A. Green