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Electronic Health Record: Name: Password
Electronic Health Record: Name: Password
Electronic Health Record: Name: Password
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LTH RECORD
RIAN MAY MARCOS
BSN 2-F
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Patients
Patient
atients
Patient
ELECTRONIC HEAL
Bianca Summer Jimenez
First Name Bianca Summer Last Name
Marital Status:
Disposition:
Discharged DAMA
Transferred Absconded
C HEALTH RECORD
Date of Admission
28-Feb-21
Pt. Number #01
Last Name Jimenez Middle Name Ferrer
Age: 25 Sex:
City: La Trinidad
Zip: 2601
Country: Philippines
Abdominal pain
Labor pain
Home
RESULTS:
Recovered Died Autopsy
Improved <48 hours No Autopsy
Unimproved >48 hours
Electronic Hea
Bianca Summer Jimenez
Previous Care for Same Condition:
Type of Treatment
Family History
13 Areas of Assessment
Home
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Drug :
Tobacco :
Occupation: Teacher
Marital Status: Married
Ins
Who is Responsible for your Bills?
If yes, Who?
Location: Date:
cation (s): List ANY/ALL medications you are CURRENTLY taking. Be Specific.
For What Condition? How long have you been taking this?
Social History:
Sexual History
Travel History
Exposure
Insurance Information:
Insular Life Philippines Health ID Card : 0123-4567-8910
his?
567-8910
__________________
_________________
Electronic He
Bianca Summer Jimenez
Review of Systems
HEENT
A. EYES YES NO
Blurred vision
Change of Vision
Double vision
Profile
Dryness
Flashing spots
Patient's History
Loss of vision
Pain
History of Present illness
Redness
RESPIRATORY YES NO
Asthma
Bronchitis
Chest pain with breathing
Chronic dry cough
Cough with mucus
Coughing up blood
Dyspnea
Emphysema
Night sweats
Pulmonary edema
Pneumonia
Produces sputum
Shortness of breath
Smoker
Tuberculosis
Wheezing
HEMATOLOGY/LYMPHATICS YES NO
Anemia
Easily bleed
Easily clot
Obs
M I
G P
LMP Feb. 28, 2021
Jaundice CLAD
Cyanosis TPWC
Pallor Anterior Neck Mass
Rash JVP
Skin Turgor Assymetric CWE
Warm to touch Lagging
Pink Sclera Retraction
Pale Sclera Hyper resonant
Nasal Discharge Equal Tactile
Ear Discharge Vocal Fremitus
Tragal Tenderness Bronchovesicular breath sound
NURSE ON DUTY:
Arian May Marcos
onic Health Record
Date of Admission
28-Feb-21 Pt. Number
Physical Examination
CLAD Crackles Rebound CN I
TPWC Wheezing Tenderness CN II
Anterior Neck Mass Rhonchi Guarding CN III
JVP Heaves/ thrills Roving's sign CN IV
Assymetric CWE PMII Obturator sign CN V
Lagging Murmur Psoas sign CN VI
Retraction Heart Sound Heel jarring sign CN VII
Hyper resonant Heart Rate Cough sign CN VIII
Equal Tactile Tympany Splenomegaly CN IX
Vocal Fremitus Soft/ rigid CN X
onchovesicular breath sound Direct CN XI
CN XII
Y: PATIENT'S NAME:
os Bianca Summer Jimenez
#01
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
nez
Electronic Healt
Bianca Summer Jimenez
Childhood Illness (es): LIST all health conditions. CHECK all past condition
Profile
Patient's History
Adult Illness (es): LIST all health conditions. CHECK all past conditions.
History of Present illness
Family History
13 Areas of Assessment
Physician’s Order
Doctor: Are Child/Adult Illnesses listed contributory to the CURRENT Cond
Nurse’s Notes
Surgery (ies): LIST all the Surgery Procedures. Write the DATE of the Proce
Home
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Injury (ies): Mark or List Injuries. Write the DATE of the Injury immediatel
nic Health Record
Date of Admission
28-Feb-21 Pt. Number #01
. CHECK all past conditions.
General Family
Father
Mother
Paternal Grandfather
Paternal Grandmother
Profile
Maternal Grandfather
Maternal Grandmother
Patient's History
Son (s)
Daughter (s)
History of Present illness
Brother (s)
Sister (s)
Past Medical History
Family History
13 Areas of Assessment
Physician’s Order
Nurse’s Notes
Home
Log Out
nic Health Record
Date of Admission
28-Feb-21
Pt. Number #01
st any specific conditions past or present after has/had.
Hypertension
Hypertension
Electronic Health R
Date of Admission
Bianca Summer Jimenez 28-Feb-21
I. PSYCHOLOGICAL STATUS
The patient is a 25-year-old female. She is married and presently residing with her
an elementary teacher. The patient and her family are Roman Catholic and have
Watching the television, eating and singing is her way in spending her leisure time
is classified under Intimacy vs. Isolation. She values her relationship with her hus
loving relationsh
Profile
II. MENTAL & EMOTIONAL STATUS
Patient's History
History of Present illness Mrs. Jimenez is having a hard time to cope up with her current situation because o
yet perform her duty on how to position the baby properly when giving breastfeedi
Past Medical History when the health worker is obta
Family History
III. ENVIRONMETAL STATUS
13 Areas of Assessment
The patient is oriented that she is in the hospital and has no sensory deficits. Sh
TPR Graphic Record procedures she is taking. Bed rails are available for the patient together with disin
She has intravenous access on her right arm for her IVF that may limit her mob
Medication and Treatment Record unnecessary noise was noted. The floor is well-main
Physician’s Order
IV. SENSORY STATUS
Nurse’s Notes During the assessment, she can also distinguish voice using the whisper test even
auditory device noted being us
Home
The patient's nose is symmetrical, proportionate and no lesions were seen. She ha
distinguish the smell of familiar o
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The patient verbalized that she has a good sense of taste. The patient is able to d
description of the food she
V. MOTOR STATUS
The patient's food is being served in the hospital. Her appetite is good and usually
on a diet as tolerated except for dark-colored foods with a Good Appetite. Teeth ar
color. Her nails were delicate and well-trimmed. There is no culture or religious di
and medications as
The patient's food is being served in the hospital. Her appetite is good and usually
on a diet as tolerated except for dark-colored foods with a Good Appetite. Teeth ar
color. Her nails were delicate and well-trimmed. There is no culture or religious di
and medications as
She goes to the comfort room with no assistance and patient urination is estimated
pain was reported to be felt during ur
During initial vital signs taking, the Patient has a pulse rate of 75 beats per minute
She has a capillary refill of 1-2 seconds. Membranes are pallo
X. RESPIRATORY STATUS
She has a respiratory rate of 17 breaths per minute. No use of accessory mus
symmetrically expands with each respi
The Patient verbalized feeling of warmth and cold. Her temperature is 36.5 C,
ventilated. The Patient is using the blanket provided by the hospital and weari
Patient’s skin is brown in color, warm, and moist. There are no scars, pallor, and j
upper and lower extremities. Her nails are yellow in color, and appears to
Patient’s skin is brown in color, warm, and moist. There are no scars, pallor, and j
upper and lower extremities. Her nails are yellow in color, and appears to
The Patient usually sleep 6-8 hours at night, she stated that sometimes her sleep
husband and sister are helping by taking care of the ba
Health Record
Date of Admission
28-Feb-21
Pt. Number #01
nd presently residing with her husband and child at Blili Km3, La Trinidad, Benguet. She works as
are Roman Catholic and have no practices or beliefs which might affect to providing health care.
y in spending her leisure time. Based on Erickson’s psychosocial theory, the patient a young adult
s her relationship with her husband. They have been married for 2 years already and have a good
loving relationship.
er current situation because of the pain she’s going through and in a view of the fact that she can’t
perly when giving breastfeeding. Also, she’s irritable and shows facial grimace during ambulation
when the health worker is obtaining vital signs.
nd has no sensory deficits. She is also knowledgeable about her condition and knows about the
the patient together with disinfectants. Drinking water and food are located in her bedside table.
r IVF that may limit her mobility. Patient is in a private room with good ventilation and and no
noted. The floor is well-maintained, and no scatter rugs were seen.
ce using the whisper test even from a distance of 2-3 feet. No corrective auditory deficits and no
uditory device noted being used by the patient.
c. Olfactory Status
d no lesions were seen. She has an intact sense of smell. No epistaxis was noted. She was able to
inguish the smell of familiar odor such as food.
d. Gustatory Status
taste. The patient is able to distinguish sweet, sour, salty and bitter foods as evidenced by proper
description of the food she was taking in.
nt was instructed to remain flat on the bed for a few hours after surgery, and then early ambulation
e she has undergone an operation. The patient can move and can move all her joints slowly and
as noted present with the patient, and all her extremities are intact and with proper symmetry. She
ds assistance whenever she needs something.
r appetite is good and usually depends on the food being served. During the hospitalization, she is
with a Good Appetite. Teeth are without dental caries. Her skin is smooth and with a pinkish white
re is no culture or religious dietary restriction reported by the patient. She can swallow in her food
and medications as well.
patient urination is estimated to be 2-3 times per shift. Urine is clear and dark yellow urine and no
as reported to be felt during urination and defecation.
mally. She urinates frequently from four to ten times a day. The color of her urine is transparent
mucosa and the tongue is pinkish in color. Skin turgor is good and the nails generally appear to be
nkish. Nail beds are good, no signs of clubbing.
se rate of 75 beats per minute and blood pressure of 120/85 mmHg while in semi fowler position.
seconds. Membranes are pallor which may suggest poor perfusion or anemia.
ute. No use of accessory muscles was noted There is no abnormal breath sounds. Chest wall
cally expands with each respiration and no retractions.
d. Her temperature is 36.5 C, per axillary upon initial vital signs taken. The ward is adequately
ded by the hospital and wearing clothes made of cotton not greatly affecting her temperature.
here are no scars, pallor, and jaundice. Edema and dermatoses is present in her face and also in her
llow in color, and appears to be clean and short. Black smooth dry hair, no lice and nits.
ted that sometimes her sleep is interrupted because of the discomfort due to her episiotomy. Her
lping by taking care of the baby while the patient take her rest period.
Electronic He
Bianca Summer Jimenez
Family Name Jimenez First Name
Date 28-Feb-21
Date in Hospital 2/28/2021
Day of PO or PP 28-Feb-21
A.M P.M A.M P.M
HOUR
7:40 MB
Profile T 106
Family History
E 102
13 Areas of Assessment
R 101
Physician’s Order
U 98
R
Nurse’s Notes 97
E
Home 96
A 140
R
130
D
I 120
A
110
C
100
R 90
A
T
E
C
R 90
A
T 80
E 70
60
R
E 50
S
P 40
I
R
A 30
T
I 20
O
N 10
Blood Pressure 120/85 mmGH
Fluid Intake 6 glasses
Urine 3
Defecation 1
Weight 50 kg
Vital
DATE Date: (February/ 28/ 2021)
SHIFT: AM PM NIGHT PRN
TIME TAKEN: 7:40
BP 120/85
TEMP (Degrees Celsius) 36.5
TEMP ROUTE (Oral,
AX
Axillary, PR, Forehead Scan)
PR 75
RR 17
O2 SAT 95%
Pain Scale:
ronic Health Record
Date of Admission
28-Feb-21 Pt. Number #01
First Name Bianca Summer Room No. #501-P Patient No. #01
A.M P.M A.M P.M A.M P.M A.M P.M A.M P.M
Vital Signs Summary
Date: (MM/ DD/ YY) Date: (MM/ DD/ YY) Date: (MM/ DD/ YY)
AM PM NIGHT PRN AM PM NIGHT PRN AM PM
#01
#01
A.M P.M
Date: (MM/ DD/ YY)
NIGHT PRN
Electronic Healt
Bianca Summer Jimenez
MEDICATION/ DOSE/ FREQUENCY DATE AM
Feb. 08:00/MB
28
Pitocin: 0.5-1 mUnit/min IV
2021
Family History
MEDICATION/ DOSE/ FREQUENCY DATE AM
Feb.
13 Areas of Assessment
28
2021
TPR Graphic Record
MEDICATION/ DOSE/ FREQUENCY DATE AM
Medication and Treatment Record
Feb.
28
Physician’s Order
2021
Nurse’s Notes
MEDICATION/ DOSE/ FREQUENCY DATE AM
Feb.
Home
28
2021
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MEDICATION/ DOSE/ FREQUENCY DATE AM
Feb.
28
2021
DATE DATE
DATE DATE
DATE DATE
DATE DATE
DATE DATE
DATE DATE
DATE DATE
DATE DATE
PM NIGHT AM PM NIGHT AM PM NIGHT
DATE DATE
DATE DATE
Electronic Health
Bianca Summer Jimenez
Date, Time and Progress Note Physician's Order / Name & S
28-Feb-21 1. Pitocin: 0.5-1 mUnit/min IV
Patient's History
Family History
13 Areas of Assessment
Physician’s Order
Nurse’s Notes
Dr. Z
Home
(08:00 AM/MB)
Log Out
c Health Record
Date of Admission
28-Feb-21 Pt. Number #01
ysician's Order / Name & Signature of Physician (Time Noted by the Nurse) Remarks
0.5-1 mUnit/min IV
e: IV 25-100mg 4 hourly
M/MB)
Electronic Health R
Date of Admission
Chevy Rolet Sparks 28-Feb-21
Family History
13 Areas of Assessment
Physician’s Order
Nurse’s Notes
Home
Log Out
Health Record
Date of Admission
28-Feb-21 Pt. Number #12345
Data Action Response
D: "Sobrang sakit na po hindi ko na kaya" verbalized by the patient. The patient-
looks uncomfortable, grimacing of face, irritable , and restlessness.
A. Monitor vital signs and assessed pain, noting location, intensity (Scale 0-10)-----
duration, provide and encourage deep breathing exercises and relaxation--------
techniques, provide comfort measures such as back rubs, and helping position---
of comfort, encourage verbalization of pain, and reviewed ways to lessen pain.
R: Patient pain was relieved and controlled.Pain rating: 2/10